
OassJlAUcfi^r 



Book._i 

Copyright N° 



COPYRIGHT DEPOSIT 



THE OFFICE TREATMENT 
OF RECTAL DISEASES 

EXPLAINED AND SIMPLIFIED 



BEING AX EXPOSITION OF THE TREATMENT OF ALL THOSE 

DISEASES, BOTH MEDICAL AND SURGICAL, OF THE 

RECTUM, ANUS, AND SIGMOID FLEXURE, THE 

CURE OF WHICH MAY BE ACCOMPLISHED 

WITHOUT SURGICAL ANAESTHESIA 



BY 

RUFUS D. MASON, M. D. 

OMAHA, NEBRASKA 

PROFESSOR OF RECTAL AND PELVIC SURGERY IN THE JOHN A. CREIGH- 

TON" MEDICAL COLLEGE, SURGEON TO ST. JOSEPH HOSPITAL, MEMBER 

OF THE AMERICAN MEDICAL ASSOCIATION, MEDICAL SOCIETY 

OF THE MISSOURI VALLEY, NEBRASKA STATE MEDICAL 

SOCIETY, OMAHA MEDICAL SOCIETY, AMERICAN 

PROCTOLOGIC SOCIETY, ETC. 

ILLUSTRATED 



THIRD EDITION 



THE BURTON COMPANY 

MEDICAL PUBLISHERS 
MINNEAPOLIS - MINN. 

1905 



UBRARY of CONGRESS 
jfwu Copies riecwveu 

JUL 24 l«U5 

COPY B. 



A 






COPYRIGHT BY 

THE BURTON COMPANY 
1905 



TO 

THE FAMILY PHYSICIAN 

WHOSE TRIALS AXD HARDSHIPS I FULLY APPRECIATE, AND WHOSE 

LABORS HAVE FOR MANY YEARS BEEN SHARED BY ME, 

THIS VOLUME IS FRATERNALLY INSCRIBED 



PREFACE 

It is not intended that this book shall take the place 
of larger works upon the same subject, but that it 
may be an addition to them, and cover many points 
that have been omitted. It is the result of many years 
practical work as a specialist and teacher along this 
line, and is a description of methods tried and found 
valuable. 

Diagnosis is discussed very briefly, merely to bring 
the malady prominently before the reader. Etiology, 
pathology, anatomy, vague theories and major opera- 
tions are omitted, and the work devoted merely to 
treatment, which is discussed in the most terse and 
practical manner possible. 

I have consulted freely the literature of the subject, 
and have made use of such portions as seemed suitable 
for a work of this kind. 

As surgical procedures are an evolution, and the 
result of many minds working along the same lines, 
it is impossible to give proper credit to any one person ; 
for this reason names of different men who have writ- 
ten upon this subject are not mentioned except in 
rare instances. 

If any excuse were necessary for this work, I 
would only call attention to the fact that there are 
many persons who suffer severely from rectal troubles 
who fear to take chloroform and undergo what to 



8 PREFACE. 

them seems a serious operation, but who would gladly 
pay for cure by less severe methods. Most of these 
people could be permanently relieved if their doctor 
knew how to go about it. The object of this book is 
to tell him how. 

It is my desire that it may be received in the pio- 
fessional spirit with which it is presented. 

Omaha, Nebraska, 1901. 



PREFACE TO SECOND EDITION 

The first edition of this book was so cordially 
received by both the professional and the medical 
press that another is necessary in less than a year 
from the time the first one was ready for delivery. 

The scope of the work has been somewhat en- 
larged, much new matter having been added, and some 
changes made in the previous text. It has also been 
more profusely illustrated. 

I wish to express my appreciation of the many 
kind words that have been received in regard to this 
little volume ; it shows plainly that such a work is 
desired by the profession, and that it covers a field 
that is not encroached upon by any similar publication. 

Omaha, Nebraska, 1902. 



PREFACE TO THIRD EDITION 

The fact that the first and second editions of this 
work have been sold in less than four years and that 
a third is now required attests the value that the pro- 
fession has placed upon it. 

The present edition has been thoroughly revised 
and much new matter added. While the work deals 
essentially with treatment, I have added more in the 
way of classification and diagnosis than were in the 
former editions. This has been done for the benefit of 
medical students and physicians in general practice 
who do not have the time to perfect themselves by 
referring to the more elaborate works written for the 
benefit of specialists. 

I have also added some things that cannot in every 
instance be done with local anaesthesia, but with the 
ever widening field into which the different local 
anaesthetics are being used, there is but very little 
of the surgery here described but what may be done 
in this way. 

As was stated in the preface to the first edition, 
no attempt has been made to write an exhaustive 
treatise on rectal diseases, as there are many most 
excellent books to be had on this subject, written by 
specialists of great ability ; but there is no short, prac- 
tical, concise book suitable for the physician in general 
practice who does not see enough rectal cases to be- 
ll 



12 PREFACE 

come familiar with them. Such a want, this book 
is intended to fill. It is also believed to be of great 
value to the student who wishes to perfect himself 
in this work sufficiently to pass a satisfactory examina- 
tion but does not care to take it up as a specialty. 

I have attempted to describe only the most easily 
done and at the same time satisfactory, operations or 
methods of treatment, such as I have made personal 
use of and found satisfactory. Others that may be 
equally good have been omitted as have also all the- 
ories and methods that have not stood the test of 
time and proof. 

Many new cuts have been added in order to more 
fully explain the text and the mechanical construction 
has been considerably improved, for which I wish 
to thank the publishers, The Burton Co., who have 
shown me favors in many ways. 

Omaha, Nebraska, 1905, 



TABLE OF CONTENTS 



Page. 

Preface 7 

Preface to Second Edition 9 

Preface to Third Edition 1 1 

CHAPTER I. 

General Considerations and Diagnosis 21 

Methods of Diagnosis 26 

Physical Examination 28 

Advance Information 34 

CHAPTER II. 

Anatomy 36 

Bones 36 

Muscles 36 

The Rectum 39 

Arteries 44 

Veins 45 

Nerves 47 

The Perineum and Ischo-Rectal Region 48 

13 



14 CONTENTS. 

CHAPTER III. 

Page. 

Constipation . . 51 

CHAPTER IV. 

Hemorrhoids 55 

Treatment 62 

The Palliative Treatment of Hemorrhoid? 64 

The Injection Method of Treating Piles 69 

Method of Operating 73 

Formulas for Injection Method J J 

Notes on the Injection Method 78 

Other Methods of Cure 80 

Operation with Continuous Suture Clamp 80 

Operation with Notched Clamp 82 

CHAPTER V. 

Abscess 91 

CHAPTER VI. 

Fistula 103 

CHAPTER VII. 

Irritable Ulcer or Fissure 120 

Treatment 121 

Operation by Incision 124 

Gradual Dilation 125 



CONTENTS. 15 

Page. 

Divulsion . . . . . 1 26 

Rectal Ulcer 126 

Treatment 128 

Ulceration of the Sigmoid 130 

Irrigation of the Colon 133 

CHAPTER VIII. 

Prolapse of the Rectum 136 

Treatment 141 

CHAPTER IX. 

Non-malignant Growths 146 

CHAPTER X. 

Proctitis and Sigmoiditis 154 

CHAPTER XI. 

Non-malignant Stricture 161 

Malignant Stricture 167 

CHAPTER XII. 

Wounds and other Injuries 171 

Treatment 172 

CHAPTER XIII. 

Pruritus Ani or itching of the Anal region 175 



16 CONTENTS. 

CHAPTER XIV. 

Page. 

Congenital Malformations 183 

CHAPTER XV. 
The Diagnosis, Symptoms and Treatment of 
Rectal Cancer 189 

CHAPTER XVI. 
The Reflex action of Rectal Diseases 195 

CHAPTER XVII. 
Rectal Examination for Life Insurance 200 

CHAPTER XVIII. 
Colostomy: Technique of operation and results. . . 207 

CHAPTER XIX. 
Local Anasthesia 214 



LIST OF ILLUSTRATIONS. 

Page. 

Fig. i. Electric head light 23 

Fig. 2. A good speculum for general use 30 

Fig. 3. Sigmoid Speculum, with long, 'smooth 

blades t 31 

Fig. 4. Laws Pneumatic Proctoscope ^ 

Fig. 5. Plaster cast of rectum, showing curves 40 s 

Fig. 6. The anal canal. — Tuttle 43 

Fig. 7. Showing venous lakelets at the termina- 
tion of hemorrhoidal veins which 
give origin to venous internal hemor- 
rhoids 46 

Fig. 8. Showing the nerve supply of the peri- 
neal and ischo rectal region 47 

Fig. 9. Female perineum. (Kelley) 49 

Fig. 10. Prolapsed internal hemorrhoids 60 

Fig. 11. A typical thrombotic hemorrhoid 61 

Fig. 12. Tuttle's rectal speculum 62 

Fig. 13. Copper Electrode for producing anaes- 
thesia of the sphincter muscles 67 

Fig. 13a Proctoscope, or Sphincterscope, to be 
used for diagnosing piles, and to ex- 
pose them to view so they may be 
grasped with forceps and drawn 
down 70 

17 



18 

Fig. 14. 

Fig-f 15. 

Fig. 16. 

Fig. 17. 

Fig. 18 

Fig. 19. 



Fig. 


20. 


Fig. 


21. 


Fig. 


22. 


Fig. 


23- 


Fig. 


24. 


Fig. 


25- 


Fig. 


26. 


Fig. 


27- 


Fig. 


28. 


Fig. 


29. 


Fig. 


30. 



ILLUSTRATIONS. 

Page. 

Slide Speculum for injecting piles, 
treating ulcers, etc 76 

O'Neill's rectal speculum for inject- 
ing piles, treating ulcers, etc 78 

Method of operating with Dr. Mason's 
continuous suture clamp 80 

Showing method of operating with the 

author's notched clamp 82 

Appearance of parts after continuous 
suture or notched clamp operation on 
hemorrhoids 82 

T forceps, to be used for grasping 
hemorrhoidal tumors 84 

Galvano cautery 86 

Sims' rectal speculum as modified by 
Van Buren 87 

Clamp for cautery operation on hemor- 
rhoids 88 

Gant's clamp for cautery operation on 
hemorrhoids 89 

Diagrammatic representation of an 
ischo rectal abscess . . . . 94 

Submucous Abscess 95 

Diagrammatic representation of a pelvi 
rectal abscess 97 

A pelvi rectal abscess which has in- 
vaded the ischo rectal fossa 99 

Showing T shaped opening in rectal 
abscess. (Goodsall and Miles.) .... 101 

Blind external fistula diagrammatically 
represented. (Goodsall and Miles.) 105 

Blind internal fistula diagrammatically 
represented. (Goodsall and Miles.) 106 



Fig. 31. 



Fig. 


32 


Fig. 


33 


Fig. 


34 


Fig. 


35 


Fig. 


36. 



Fig. 37 
Fig. 38 

Fig. 39 

Fig. 40 

Fig. 41 

Fig. 42, 
Fig. 43 

Fig. 44 

Fig. 45 

Fig. 46 



ILLUSTRATIONS. 19 

Page. 

A complete fistula diagrammatically 
represented. (Goodsall and Miles.) 108 

Fistula 109 

Diagrammatic representation of a sub- 
mucous blind fistula resulting from 
a fissure 113 

Grooved director for operating on 
fistula 116 

Horseshoe fistula. Lines of incision 
in operating 117 

Complete fistula, showing how pus may 
burrow beneath the mucous mem- 
brane both below and above the open- 
ing into the bowel 118 

Typical irritable ulcer or fissure. ..... 121 

Dilators for gradual dilation of sphinc- 
ter 125 

Cylindrical speculum for examining the 
higher parts of the rectum 127 

A good sponge and cotton holder for 
rectal work : . 128 

Pile pipe for applying ointment to 
ulcers 129 

Double current irrigating tube 135 

Complete prolapse of the rectum. (Tut- 
tle.) 139 

Incomplete prolapse of the rectum. 
(Tuttle.) 141 

Complete prolapse originating above 
the internal sphincter. (Tuttle.) . . . 144 

Complete prolapse which begins high 
in the rectum or sigmoid and does 
not appear outside. (Tuttle.) 145 



20 ILLUSTRATIONS. 

Page. 

Fig. 47. Vertical section of simple adenoid. 

(Kelsey.) 149 

Fig. 48. Multiple adenoma of rectum. (Tut- 

tle.) 150 

Fig. 49. Syphilitic condylomata. (Kelsey.).... 152 
Fig. 50. Snare for polypus and other small 

growths 153 

Fig. 51. Annular stricture 163 

Fig. 52. Wales rectal bougie 168 

Fig. 53. Tubular stricture 169 

Fig. 54. Showing rectum ending in a blind 

pouch. (Kelsey.) 185 

Fig. 55. Rectum ending in a, blind pouch; anus 

normal. (Kelsey) 186 

Fig. 56. Showing rectum ending in the bladder. 

(Kelsey) 187 

Fig. 57. Rectum ending in Glans Penis. (Kel- 
sey.) 188 

Fig. 58. Inquinal Colostomy. (Bodine.) 209 

Fig. 59. Enterotomy after Colotomy. (Bodine.) 210 
Fig. 60. Showing how the bowel passes be- 
tween the internal and external 
oblique muscles for about an inch be- 
fore emerging through the skin 211 



CHAPTER I 

GENERAL CONSIDERATIONS AND DIAGNOSIS. 

I believe any medical man in general practice 
will agree with me that there is no class of diseases 
that he is called upon to treat in which he obtains as 
unsatisfactory results as in those designated "Rectal." 
All will admit that they are exceedingly common, 
and that those afflicted are great sufferers, many 
being entirely unable to perform labor of any kind ; 
these people are not only willing but anxious to be 
cured, and most of them will gladly pay for permanent 
relief. Why, then, does not the physician cure them, 
and thus not only largely increase his earnings, but 
receive the grateful appreciation of his patrons? The 
reason in most cases is, that the general practitioner 
thinks there is something mysterious and obscure 
about these troubles, making them hard to understand, 
and harder still to treat. I admit that many of them 
are difficult to diagnose, and that the treatment is 
often very perplexing, even to those who limit their 
practice to this kind of work, but after many years' 
experience, I am confident that fully fifty per cent 
of these cases can be properly diagnosed and treated 

21 



22 TREATMENT OF RECTAL DISEASES 

by the average physician, provided he will take the 
trouble to go about it in the right way. 

Many seem to think that a large number of special 
appliances and costly instruments is needed, and that 
no one but a specialist is capable of using these after 
they are purchased. In many instances this is true, 
but for most of the cases seen by the general prac- 
titioner, only the ordinary instruments usually at his 
command are needed. A wooden table, such as any 
carpenter can make, will do in place of an expensive 
operating chair or table. A cheap irrigator can easily 
be made by removing the bottom from a large gallon 
bottle and hanging it inverted in a net work of string 
or small chain with the cork securely wired in and 
a glass tube inserted through it, to which four or five 
feet of rubber tubing are attached. 

Some sort of closet should be arranged so that 
enemata may be given. There are many cheap forms 
of these on the market, or one can be made at small 
expense. This can be shoved under some piece of 
office furniture, or surrounded by a neat curtain, so 
that it will be hidden from view when not in use. Tt 
is not often that it will be needed, but it is indispens- 
able in certain cases. The use of this piece of furni- 
ture brings up an objection often made by physicians 
against treating these cases, that "it is dirty work." 
I admit that there are some unpleasant features about 
it, as there are about any work that one may adopt, 
but I am sure that the treatment of rectal diseases 
is not as unpleasant as that of genito-urinary or obstet- 
rical work. People who consult their doctor about 
these troubles will usually clean themselves pretty 
thoroughly before coming, even though not ordinarily 
neat, and if the doctor can, as is usually the case, make 
an appointment with them in advance, he can tell 



GENERAL CONSIDERATIONS 23 

them to wash out the bowels well with large quanti- 
ties of hot water, and also to use plenty of water on 
the outside. This need not offend even the most 
sensitive, as it can be explained that it is necessary 
to "relax the parts." If this is well done, this portion 
of the anatomy is as clean as any other part of the 
body, and should it be necessary to give an enema in 
the office, nothing comes from the patient except the 
water introduced. 

A good light is necessary, and daylight is the 
best, although this may be aided by artificial means. 
The use of the little electrical lamps that can be carried 
around is often a great help, but is not an absolute 
necessity. 




Fig. 1. Electric head light. 

Other instruments needed will readily be suggested, 
such as T-forceps, artery forceps, probes, directors, 
scissors, knives, hypodermics, etc. 

As to the best way to make an examination, I 
believe it is always wise to let the patient tell his or 
her own story uninterruptedly. They usually think 
they have piles, and often tell much that is unneces- 
sary, but this serves to wear off the embarrassment, 
and a few w r ell-directed questions in conclusion will 
clear up the diagnosis as far as it it can be done in 
this way. It seems hardly necessary to say that no 
case, however trivial it may seem, should be treated 
without a careful examination. Some most amusing- 



24 TREATMENT OF RECTAL DISEASES 

and serious blunders have come under my notice from 
neglecting this. 

Lady patients should, if possible, be accompanied 
by their husbands, if married, otherwise by some fe- 
male friend who can assist them in arranging their 
clothings getting on the table, etc. After this has been 
done, and the patient is lying on her left side covered 
by a sheet, the doctor can make his examination with- 
out embarrassment to either party. He may be able 
to arrive at a proper diagnosis at a glance, or only 
after considerable trouble 

It is well to state in this place what can readily 
be seen and felt with the unaided eye and finger. 
There can easily be seen external hemorrhoids, the 
external opening of fistulae, the thickened or parch- 
ment-like or eczematous skin of pruritus. The moist 
appearance indicating a catarrhal condition of the bow- 
el farther up, fissures, partly prolapsed internal hemor- 
rhoids, venereal diseases, abscess, and after a little 
experience, the bulging or unusually prominent ap- 
pearance of the parts due to internal hemorrhoids 
may be recognized. There may be felt upon the out- 
side the old tracks of fistulae, and by gently pulling 
the anal opening apart with the thumb and finger, 
fissures and irritable ulcers are recognized that are 
too high to come into view without doing this. Oc- 
casionally the lower part of polypoid growths, or pin- 
worms, may be seen. By introducing the oiled finger 
into the bowel there may be felt, first the condition of 
the external sphincter muscle. It will be found to 
vary greatly in different persons. In the aged, infirm 
and debilitated it will in most cases be found weak 
and relaxed, as it is also in many persons who have 
been troubled for a long time with large internal hem- 
orrhoids, due to their constant protrusion and return, 



GENERAL CONSIDERATIONS 25 

which gradually weakens the muscle and causes it 
to lose to a large extent its strength and firmness. In 
the young and vigorous the muscle will be found to 
be firm and resisting, contracting tightly on the in- 
truding finger. Sudden force should not be used, 
but gentleness will overcome the resistance. Pain 
is usually not complained of in the healthy muscle, 
but if a fissure or irritable ulcer be present it will be 
very severe. Farther on may be felt the internal open- 
ing of fistulse, the depressed rough edge of ulcers, 
polypi, and strictures if not too high, hemorrhoids if 
well developed, although it requires considerable ex- 
perience to distinguish these with the finger, and in 
most cases it cannot be done even by the most expert 
examiner. By pressing the finger as far as possible 
all of that portion of the bowel likely to be diseased 
may be felt, and experience will soon teach one to 
distinguish the prostate, neck of the bladder, coccyx, 
uterus, etc. Some experience is required to make out 
all of these, but by frequent examinations one soon 
becomes quite expert. In examining women the fin- 
ger may be introduced into the vagina and the whole 
anterior wall of the bowel turned out. In this way 
internal hemorrhoids, and any other abnormal con- 
ditions, in most cases, may be readily recognized. 

Another point that should not be overlooked is 
that there may be a complication of diseases. It would 
certainly be very unwise to treat a patient for external 
piles and overlook a stricture. It is not uncommon 
to have patients come for treatment for some disease 
that is wholly dependent upon some other trouble 
that to them is unimportant, such as a pruritus ani du»e 
to a vaginal discharge, or a prolapse caused by inter- 



2G TREATMENT OF RECTAL DISEASES 

rial piles which force the mucous membrane down 
but do not themselves protrude. 

I have known a patient to be treated in a hospital 
for three weeks for this disease, while the hemorrhoids 
which were producing it were undiscovered. 

METHODS OF DIAGNOSIS. 

While much may be learned from the description 
of symptoms as given by the patient, it is only prelimi- 
nary to the examination that is to follow. It is far 
too often the case that the family physician makes no 
effort to learn the exact condition other than as given 
by the patient and as a result the treatment is carried 
out along wrong lines. It is not uncommon for 
patients to go to specialists for treatment thinking 
they have hemorrhoids, when they are really suffering 
from an advanced stage of cancer, this too, after 
having received much treatment from their home 
doctor. 

Taking up the subjective symptoms first, those 
most often complained of will be discussed. 

Protrusion at Stool. This causes the patient to 
seek the advice of a physician more often than any 
other one thing. It may be caused by hemorrhoids, 
prolapse, polypoid growth or other tumor. As the 
diagnosis of each of these conditions is to be found in 
the proper place, it is only referred to here to show 
the futility of trying to make a correct diagnosis with- 
out examination. 

Pain. This will often suggest pretty accurately 
the nature of the disease. If of recent date it is prob- 
ably of an inflammatory nature as an abscess or fis- 
sure. Internal piles as a rule are not painful. If of 
long standing, it may be carcinoma, a tumor high in 



GENERAL CONSIDERATIONS 27 

the bowel, a syphilitic deposit, or a chronic ulcer. The 
character of the pain may be important ; if of a throb- 
bing character it shows inflammation and the prob- 
able formation of pus or possibly the strangulation 
of internal piles ; if of a pricking or stabbing nature 
it might indicate some foreign body. The time at 
which it occurs may indicate the cause ; if it follows 
a bowel movement and lasts from two to four hours 
and is of a sharp lancinating character it is almost 
surely due to a fissure. 

Hemorrhage. When blood is passed from the 
bowel it nearly always comes from capillary piles or 
from venous tumors that are constricted by the sphinc- 
ter muscle so that the blood is forced out of the vein 
wall. In either case the blood is lost at stool. If 
the amount is small and is noticed immediately fol- 
lowing a bowel movement and is accompanied with 
pain of a lancinating, aching character it probably 
comes from a fissure. If it comes on independently 
of the bowel movements it may be due to carcinoma 
or ulcer or it may come from the bowel above the 
rectum. If the attack comes on suddenly and has 
not been noticed before it may be due to some foreign 
body that has lacerated the bowels. 

Discharge of Mucus, Pus, etc. Mucus may be 
due to internal piles, catarrhal proctitis, or anything 
that causes an irritation, as polypoid growths, hard dry 
fecal matter, etc. Pus is from an internal incomplete 
fistula or abscess, and pus mixed with blood is from 
an ulceration, a carcinoma, tumors or stricture. The 
symptoms accompanying the discharge, as pain and 
the length of time that it has existed, will assist in the 
diagnosis. 

Diarrhxa. A diarrhoea due to rectal disease is 
generally caused by an acute proctitis and is accom- 



28 TREATMENT OF RECTAL DISEASES 

panied by great pain, tenesmus, and symptoms of 
heat both local and general. If the diarrhoea alter- 
nates with constipation it may indicate a stricture. 
If there is constipation so that the fecal matter be- 
comes dry and hard it may so irritate the bowel wall 
that an explosive diarrhoea is the result. After this 
has subsided the conditions that produced it gradually 
return and it occurs again. 

Constitutional Symptoms. Many rectal diseases 
have a striking effect on the general health and the 
constitutional symptoms are as marked as the local 
ones. Among these are the cancerous cachexia, ner- 
vousness, anemia and loss of weight. Any one or all 
of these may be present. 

Cachexia. This will at once suggest cancer and, 
if combined with loss of weight extending over a 
period of several months, is quite a sure indication 
of this disease. 

Nervousness. Rectal diseases in general are sub- 
ject to many reflex nervous symptoms caused especi- 
ally by hemorrhoids, fissures and those that involve 
numerous nerve filaments. For further information 
the reader is referred to the chapter on the reflex 
action of rectal diseases. 

PHYSICAL EXAMINATION. 

Preparation of the Patient. In nearly all cases it 
is better to have the patient thoroughly wash out the 
bowel before coming to the office, but in some dis- 
eases it is important to make the examination first in 
order to ascertain whether or not the rectum contains 
fecal matter, blood, pus, etc. The internal opening 
of an incomplete fistula might not be found if all the 
pus is washed out just before the examination. After 



GENERAL CONSIDERATIONS 29 

having made the examination an enema should be 
given and the patient requested to retire to the toilet 
room and strain as hard as possible to bring out any 
protrusion that may be present. They should be 
cautioned to not push back any thing that may be out 
before getting on the operating table. 

Position of Patient. For all general purposes the 
left lateral position is the best. It is the most com- 
fortable for the patient and fills all requirements on 
the part of the doctor. In persons who are very fleshy 
the lithotomy position is much to be preferred as the 
buttocks do not obstruct the view as they do when 
the patient is lying on his side. When the lithotomy 
position is used it should be an exaggerated form with 
the head lower than the body and the legs and thighs 
well flexed. When it is necessary to introduce the 
sigmoidoscope this position will prove the most satis- 
factory and much more comfortable to the patient. 

This position is also very desirable when it is neces- 
sary to examine other organs, as the vagina, bladder, 
uterus, or the contents of the abdomen. 

I have seldom found it necessary to ask a patient 
to assume the knee-chest posture. This position is 
very uncomfortable and embarrassing especially to 
females. Still it has advantages not possessed by any 
of the others, one of which is, that owing to the 
flexure of the lumbar portion of the spine the pelvis 
is tilted backward thus exposing the anal region more 
fully than in any other way. It also has the advantage 
of having all of the abdominal organs fall away from 
the pelvis by the force of gravity, thus straightening 
the rectum somewhat. 

In some cases where there is a protrusion that 
recedes easily it is important that it be examined while 
the patient is in the squatting position, otherwise it 



30 TREATMENT OF RECTAL DISEASES 

will slip back before he can get on the table and a 
correct diagnosis will be impossible. 

Instrumental Examination. As a rule but very 
little information can be obtained by an examination 
with the speculum. They simply push the parts out 
of sight behind the broad steel blades and the true 
condition is not seen, or if an instrument is used with 
wire blades the tissue falls between the wires at the 
verge of the anus so that the parts above are not seen 
at all. At best but two or three inches are exposed 
to view and all that can be seen may easily be recog- 
nized by the educated finger without the speculum. 
When to this is added the fact that this instrument is 
exceedingly painful it is seen that its use is very limit- 
ed and is seldom called for except when general 




Fig. 2. A good speculum for general use. 



anaesthesia is induced. Still a number of these specula 
should be kept on hand and in cases where the sphinct- 
er is not too tight and no inflammatory condition ex- 
ists they may be used with considerable satisfaction. 
The small conical slide speculum does not offer the 
same objection that the others do and for treating 



GENERAL CONSIDERATIONS 



31 



hemorrhoids by injection, making applications to ul- 
cers, fissures, etc., they are most excellent. 

In 1895 Howard "Kelley described a set of long 
straight tubes which could be introduced into the 
upper part of the rectum, thus showing plainly prac- 
tically all of the organ up to the sigmoid. Since 
that time Law, Tuttle, Pennington and others have 
improved upon the method until now they are very 




Fis 



3. Sigmoid Speculum, with long, smooth blades. 
Easy to introduce and not very painful. 



complete. As now arranged, a glass cap is screwed 
over the outer end and a rubber bulb attached by means 
of which air may be forced into the bowel, thus bal- 
looning it so that all folds in the mucous membrane 
are effaced and the entire surface brought into per- 
fect view. Anaesthesia is not required in using these 
tubes and if the knee-chest or lithotomy position is 
assumed but little if any pain will be experienced. 
After the instrument has passed the internal sphincter 
muscle the obturator should be removed and the air 
will at once rush in and balloon the lower part of the 



32 TREATMENT OF RECTAL DISEASES 

rectal pouch but the upper portion and the sigmoid 
will not dilate except by forcing the air in. Before 
the instrument is removed the cap should be taken 
off and pressure made on the abdomen to get all the 
air possible out of the colon, otherwise the patient may 
suffer severely from colic. One of these tubes should 
be made quite short, not to exceed two inches, for 
examining the lower part of the bowel. 

In examining female patients it is important that 
all the pelvic organs be carefully looked after. Many 
times the uterus, ovaries or tubes are more at fault 
than the rectum and the examiner who is not compe- 
tent to diagnose and treat all abnormal conditions 
found here is not as a rule competent to treat any of 
them. 

Exploratory Laparotomy. If there is strong reason 
to suspect disease of the bowel too high to diagnose 
from below, the abdomen should be opened and the 
true condition ascertained. Arrangement may be 
made to operate at the same time if the consent of 
the patient and friends is obtained and the conditions 
justify it; or this may be postponed until some future 
time as thought best. With present methods of asep- 
sis there is but little danger in an exploratory incision. 

I give below a copy of advance information that 
I have had printed in the form of little slips and when 
I know that a patient is coming to see me for the first 
time I give or send one to him and in this way find 
that he is almost invariably well prepared for an 
examination. 

I also give the form of some cards that I keep on 
hand to record my cases. These cards are kept ar- 
ranged in alphabetical order and are a very great con- 
venience for future reference. They can be filled while 
the history is being taken and are but little bother. It is 



GENERAL CONSIDERATIONS 



33 



a great convenience in case some one whom you 
treated a year or more ago writes or calls on you, 
to be able to look the matter up at once "and 
not have to depend on memory. I carry a few of 



o €S 




Fig 4. Laws Pneumatic Proctoscope. E, 1 2 3 obtura- 
tors; A, B, C, tubes; D, handle; f/ cap with o ass 
window, G inflating bulb; H, battery connection?/ 
K, electric light and insulating rods. 



these in my pocket and should a case be seen 
in the hospital or at the patient's home the record can 
be taken. In case there is not enough room the back 
may be used. The letters "M. F." stands for male or 
female, and "M. S. W." for married, single or widow, 
(or widower). Simply cross out the ones not wanted. 



34 TREATMENT OF RECTAL DISEASES 

ADVANCE INFORMATION. 

If you are coming to me for treatment of rectal 
disease, please observe the following advice: Two 
days before you expect to be in my office for ex- 
amination take a good physic. It is not so very 
important what it is so it acts freely, but two or 
three of the compound cathartic pills which any 
druggist will furnish you will be the best. This 
should be followed the next day zcith a few small 
doses of Rochcllc salts, say a heaping teaspoonful 
in a cup of water, preferably hot. The evening 
before coming, take one or more injections of 
hot water to which has been added a little soap. 
If you are not to get to the office until afternoon 
it is well to repeat the injection in the morning 
before coming. 

A little trouble on your part will save you con- 
siderable annoyance and possibly a day or more 
of time, besides being much more pleasant for 
both of us. 

Please keep this slip for future reference, if you are 
not coming now. 

R. D. MASON, M.D., 
Brown Block, corner 16th and Douglas Sts. 
Omaha, Neb. 



GENERAL CONSIDERATIONS 



35 



O 



fc« 






^ ^ fc. 



^ 






CHAPTER II 
ANATOMY. 

In order to have a correct knowledge of rec- 
tal diseases and their treatment it is essential that 
a clear understanding be had of the normal anatomy 
of the parts. It is not necessary to go into the sub- 
ject very carefully and describe each part in detail 
as it would take up too much space, but .the essential 
points will be gone over with sufficient clearness to 
give a good working knowledge of the parts. 

BONES. 

The bones of the pelvis consist of the two ossa- 
innominata, which bound it on either side and in front; 
the sacrum and coccyx which complete it behind. 
These form a broad, cup-shaped cavity which is said 
to resemble a basin. It is the most "strongly construc- 
ted of the bony frames of the body and is interposed 
between the spine which it supports and the lower ex- 
tremities upon which it rests. 

The pelvis is divided into two cavities by the illio- 
pectineal line, that above this line being called the 
false pelvis and that below the true pelvis. Most of 
the organs under consideration are in the true pelvis. 

MUSCLES. 

Beginning from the outside the first muscle is the 
sphincter Ani Externus or external sphincter. This 
is a true sphincter and surrounds the terminal portion 
of the large intestine. It arises from the dorsal as- 

3G 



ANATOMY 37 

pect of the tip of the coccyx and also the ano-cocy- 
geal ligament ; and after dividing- to surround the anus, 
is inserted into the central point of the perineum. This 
muscle consists of two strata, a superficial and deep. 
The former is mostly subcutaneous and the fibres are 
inserted into the skin while the deep fibres are in- 
serted into the outer layer of the rectal wall. This 
is a purely voluntary muscle, and, being under the con- 
trol of the will, is of the utmost importance. It re- 
laxes readily during the passage of feces and contracts 
to its former position after the bowel has been emp- 
tied. While it is a voluntary muscle it is not entirely 
under the control of the will but is largely so. 

Because of its exposed position it is very subject 
to injury and often becomes hypertrophied and more 
or less firmly contracted so that it offers considerable 
resistance to the passage of feces, and divulsion or 
stretching is necessary to overcome the resulting con- 
stipation. 

The nerve supply is from the inferior hemorrhoi- 
dal branch of the pudic and the perineal branch of the 
fourth sacral. 

Internal Sphincter. This muscle is simply a hyper- 
trophy of the lowermost circular muscular fibres of 
the rectum. It is an involuntary muscle and keeps 
the canal closed when the will power is not under 
control, as in sleep, anaesthesia, etc. The division of 
this muscle will occasionally result in partial inconti- 
nence, although if properly done this is not likely to 
occur. 

There is said to be a third sphincter above this 
but it is of so little importance that it will not be 
further considered. 

Levator Ani. The description of this muscle as 
given by Grey is as follows : "The Levator Ani is a 



38 TREATMENT OE RECTAL DISEASES 

broad, thin muscle, situated on each side of the pelvis. 
It is attached to the inner surface of the sides of the 
true pelvis, and, descending, unites with its fellow of 
the opposite side to form the. floor of the pelvic cavity. 
It supports the viscera in this cavity, and surrounds 
the various structures which pass through it. It arises, 
in front, from the posterior surface of the body and 
the ramus of the pubes, on the outer side of the 
symphysis ; posteriorly, from the inner surface of the 
spine of the ischium ; and between these two points, 
from the angle of the division between the obturator 
and recto-vesicle layers of the pelvic fascia at their 
under part ; the fibres pass downward to the middle 
line of the floor of the pelvis, and are inserted, the 
most posterior fibres into the sides of the apex of the 
coccyx ; those placed anteriorly unite with the muscle 
of the opposite side, in a median fibrous raphe, which 
extends between the coccyx and the margin of the 
larger portion of the muscle, are inserted into the sides 
of the rectum, blending with the fibres of the sphincter 
muscle ; lastly the anterior fibres, the longest descend 
upon the side of the prostate gland to unite beneath 
it with the muscle of the opposite side, blending with 
the fibres of the external sphincter and transversus 
perinsei muscles at the tendinous centre of the peri- 
neum." This muscle forms the floor of the pelvis, di- 
viding the contents of the true, from that of the false 
pelvis. Its function is to hold the contents of the 
upper pelvis and abdomen away from the anal outlet. 
It also acts by compression as an aid in forcing the 
contents of the bowel out in defecation and at the 
same time by the contraction of its fibres the neck of 
the bladder is compressed and the urethra closed. It 
receives its nerve supply from the perineal branch of 



ANATOMY 39 

the fourth sacral and the deep branch of the perineal 
division of the pudic. 

Coccygcus. "This muscle is behind and parallel 
with the preceding. It is a triangular plane of muscu- 
lar and tendinous fibres, arising, by its apex, from the 
spine of the ischium and the lesser sacro-sciatic liga- 
ments, and inserted, by its base, into the margins of 
the coccyx and into the sides of the lower piece of 
the sacrum. This muscle is continuous with the pos- 
terior border of the Levator Ani, and closes the back 
part of the outlet of the pelvis. Its action is to raise 
and support the coccyx after it has been pushed back 
during defecation or parturition." The nerve supply 
same as the Levator Ani. 

Transversus Pcrinci. "This is a narrow muscular 
slip, which passes more or less transversely across 
the back part of the perineal space. It arises by a 
small tendon from the inner and fore side of the tuber- 
osity of the ischium, and, passing obliquely forward 
and inward is inserted into the central tendinous point 
of the perineum, joining in this situation with the 
muscle of the opposite side, the sphincter ani behind, 
and the accelerator urinae in front." In the female 
this muscle is inserted into the side of the sphincter 
vagina, and the Levator Ani into the sides of the 
vagina and rectum. 

THE RZCTUM. 

This constitutes the lower eight or nine inches of 
the large intestine and extends from the left sacro- 
illiac-synchondrosis, at which point it is a continua- 
tion of the sigmoid flexure, to the anus. This organ 
is not straight but has three distinct curves as follows : 
From its starting point at the left of the spinal column 



40 TREATMENT OF RECTAL DISEASES 

it extends downward and backward into the hollow 
of the sacrum and at the same time it curves to 'the 
right so that it lies in the center of the body instead 
of at the left ; after reaching the hollow of the sacrum 
it curves forward until it reaches the tip of the coccyx 
when it again turns backward until it reaches the out- 
side. It somewhat resembles the letter S and these 




Pig. 5. Plaster cast of rectum, showing curves. 

curves should be borne in mind when attempting to 
pass instruments. For facility of description the rec- 
tum is divided into three parts as follows: The upper 
portion from the starting point to the middle of the 
third piece of the sacrum ; the second from this point 



ANATOMY 41 

to the tip of the coccyx; and the third from there to 
the lower end. 

Upper Portion. This is from four to five inches 
in the adult and is entirely covered by peritoneum 
which forms a meso-rectum which attaches it to the 
back part of the pelvis. As before stated it is directed 
downward, backward, and to the right, and ends at the 
middle of the third piece of the sacrum. This portion 
is very similar to the bowel above and some claim 
should not be classed as part of the rectum. 

Relations. Coils of small intestines, the bladder 
when distended, the uterus when enlarged, and the 
ovaries and tubes are in front and extending on each 
side. Behind lie the three pieces of the sacrum, the 
pyriformis muscle, and the meso-rectum containing the 
hemorrhoidal vessels. On the left are the ureter and 
branches of the internal illiac artery. 

Middle Portion. This is about two and a half 
inches long and extends from the middle of the third 
piece of the sacrum to the tip of the coccyx. The 
most of this portion is covered by peritoneum in 
front and at the sides but not behind ; for this reason 
the rectum is not attached to the pelvis at this point, 
having no meso-rectum, but is freely movable. In 
front the peritoneum in the male is reflected onto the 
bladder, and in the female onto the vagina forming 
Douglas pouch. 

Relations. In front, in the male, the recto-vesical 
pouch of the peritoneum, the base of the bladder, the 
seminal vessicles, and the prostate. In the female, 
Douglas pouch and the posterior wall of the vagina. 
Behind there is nothing but the concave portion of 
the sacrum and some loose areolar tissue together 
with a few lymphatic glands. 



42 TREATMENT OP RECTAL DISEASES 

Lower Portion. This measures about one and a 
half inches and extends from the tip of the coccyx 
backward to the outside. It is surrounded by both 
the internal and external sphincter muscles which re- 
duces it to a narrow closed canal. This is the part 
that is the most exposed to traumatism and where 
we may expect to find hemorrhoids, fistulas, fissures, 
etc. There is no peritoneum around this portion. 

Relations. In front in the male are to be found 
the apex of the prostate, the base of the bladder, the 
triangular ligament, the perineal body, and the ureth- 
ra. In the female the lower part of the posterior 
wall of the vagina and the perineal body. Behind 
are the ano-coccygeal ligament, the posterior fibres 
of the levators ani and the origin of the external 
sphincter. On each side are to be found the ischio- 
rectal fossa. 

Structure of the Rectum. There are four coats, 
the serous, muscular, sub-mucous and mucous. 

The Serous Coat. This is the peritoneum and has 
been described in speaking of the curves to which the 
reader is referred. 

Muscular Coat. The muscular fibres are arranged 
in two district layers, the outer longitudinal and the 
inner circular. The longitudinal is a continuation of 
that found in the colon and is divided into three layers ; 
the outer is inserted into the pelvic fascia, the middle 
blend with those of the levator ani, and the internal 
pass down by a series of fine tendons between the in- 
ternal and external sphincter muscles and are insert- 
ed into the skin at the anal margin. The circular 
fibres are for the most part uniformly distributed but 
at the lower end they are gathered into a thick band 
constituting the internal sphincter, which has been de- 
scribed. 



ANATOMY 



43 



The Sub-mucous Coat. This is the coat in which 
the vessels, nerves, and lymphatics are to be found. 
It is a loose mass of areolar tissue inside the muscular 
layer and upon which rests the mucous membrane. 

The Mucous Membrane. This is very vascular 
and moves freely on the sub-mucous tissue. When at 
rest it is thrown into folds which are mostly effaced 
when the bowel is distended. Certain of these are 
not effaced during distention, these are called Hous- 
ton s folds. Immediatelv above the muco-cutaneous 




Fig. G. The anal canal. A, columns of Morgagni; B, semi- 
lunar valves or crypts of Morgagni; C, dentate border, 
marking upper limits of anus and surmounted by papil- 
lse: D, Hilton's white line. — Tuttle. 



junction are other folds running in a longitudinal di- 
rection and called the "Columns of Morgagni." These 
are no doubt caused by the constricting effect of the 
sphincter muscle. Between these columns are to be 
seen folds of mucous membrane called pockets and 
more correctly known as the "Valves of Morgagni." 
These so-called pockets are a source of great profit 



44 TREATMENT OF RECTAL DISEASES 

to many irregular practitioners as they tell their pa- 
tients of the direful results that will ensue if they are 
not cut out. They promise to cure anything from 
corns to consumption by cutting out these pockets. 
There is some doubt as to their exact function, but it 
is now believed by most authorities that they are to 
gather and hold mucus to lubricate the fecal mass in 
passing out and thus protect the mucous membrane 
from injury. Ball says they are often torn loose at 
the edges by hard fecal passages and gradually work 
down in the form of a hard mass called a sentinal 
pile. The torn tissue above them results in an irrit- 
able ulcer. 

ARTERIES. 

Superior Hemorrhoidal. This artery is a direct 
continuation of the inferior mesenteric and descends 
into the pelvis between the layers of the meso-rectum, 
crossing, in its course, the ureter and the left common 
illiac vessels. Opposite the middle of the sacrum, it 
divides into two parts which descend one on each side 
of the rectum, where they divide into several small 
branches which are distributed between the mucous 
and muscular coats of that tube, nearly as far as its 
lower end ; anastomosing with each other, with the 
middle hemorrhoidal arteries, branches of the internal 
illiac, and with the inferior hemorrhoidal branches of 
the internal pudic. 

The student should especially nol^e that the 
trunk of the vessel descends along the back part of the 
rectum as far as the middle of the sacrum before it 
divides, this is about a fingers length or four inches 
from the anus. In operating on this part of the bowel 
this should be remembered and great caution be used. 

The Middle Hemorrhoidal Artery is a branch of 



ANATOMY 45 

the anterior division of the internal illiac. It is dis- 
tributed mainly to the middle portion of the rectum 
and its branches anastomose freely with the superior 
hemorrhoidal. It supplies chiefly the muscular layer 
of the bowel. 

The Inferior Hemorrhoidal Artery is a branch of 
the internal pudic as it passes above the tuberosity 
of the ischium. It crosses the ischo-rectal fossa and 
is distributed to the muscles and integument of the 
anal region. This artery or some of its branches are 
often cut in operations for fistula, but as they are 
small they seldom require ligating. 

VEINS. 

The veins of the rectum are very numerous and 
are known as the superior, middle and inferior hemor- 
rhoidal to correspond with the arteries. These are 
in the form of a venous plexus rather than individual 
veins. 

The Superior Hemorrhoidal vein collects the blood 
from the rectum itself, and not much from the sur- 
rounding parts, and empties it through the messen- 
teric into the portal system. The middle and inferior 
hemorrhoidal veins collect the blood from the external 
surface of the anus and skin and return it into the vena- 
cava. The dividing line is said to be the muco-cutan- 
eous junction. For this reason it is easily seen that 
internal hemorrhoids are always an affection of the 
superior hemorrhoidal veins while the external are 
always connected with the middle or inferior hemor- 
rhoidal. Slightly above the muco-cutaneous junction 
there are many small venous pools of blood in the 
shape of little lakelets, each distinct in itself and yet 
freely anastomosing with the others. They are just 
under the mucous membrane and extend entirelv 



40 



TREATMENT OF RECTAL DISEASES 



around the bowel. About a fingers length above the 
anus, venous branches enter the bowel wall through 
holelike apertures. The ingenious theory has been ad- 
vanced that the contraction of these slits, due to con- 
stipation, straining at stool, etc., by impeding the 
circulation is a potent cause of hemorrhoids. As the 



i Mm 



bs 



. if -WwCf^£l ' i 



wij 







Fig. 7. Showing venous lakelets at the termination of 
hemorrhoidal veins which give origin to venous in- 
ternal hemorrhoids. 



veins have no valves and because of the lake-like 
arrangement below this point, as previously noted, 
the theory is a very sensible one. 

The Middle Hemorrhoidal is distributed to the 
outer surface of the rectum above the levator ani 



ANATOMY 



47 



muscle. It receives the blood from the muscular coats 
of the bowel and does not anastomose very freely with 
the other veins. 

The Inferior Hemorrhoidal is arranged around the 
sub-cutaneous tissue of the anus and is the venous 
plexus involved in external hemorrhoids. 

NERVES. 

These are from the spinal and sympathetic sys- 
tems. The latter are from the inferior mesentric and 
hypogastric plexus and are distributed to the muscular 
coat and mucous membrane including the internal 
sphincter. 




Fig. S. Showing the nerve supply of the perineal and 
ischo-rectal region. 



The spinal nerves are from the third and fourth 
sacral and the pudic. The fibres enter the rectum be- 
tween the internal and external sphincter muscles and 
are distributed very freely to the lower end of the 
bowel and adjacent skin. Owing to this free distri- 
bution, operations here are the most painful of any 



48 TREATMENT OF RECTAL DISEASES 

in surgery. This is also especially noticable in cases 
of fissure. The fact that these same nerves are dis- 
tributed freely to the bladder, prostate, urethra, etc., 
accounts for the pain felt in these organs in case of 
rectal disease as it does also for retention of urine in 
operations in this region. 

THE PERINEUM AND ISCHO-RECTAL REGION. 

"This corresponds to the inferior aperture or out- 
let of the pelvis. Its deep boundaries are, in front, 
the pudic arch and super pubic ligament, behind, the 
tip of the coccyx ; and on each side, the ramus of the 
pubes and ischium, the tuberosities of the ischium, and 
the great sacro-sciatic ligament. The space included 
by these boundaries is somewhat lozenge-shaped, and 
is limited on the surface of the body by the scrotum 
in front, by the buttocks behind, and on each side by 
the inner side of the thighs. It measures, from before 
backward, about four inches, and about three in the 
broadest part of its transverse diameter, between the 
ischial tuberosities. A line drawn transversely be- 
tween the anterior part of the tuberosity of the ischi- 
um, on each side, in front of the anus, sub-divides this 
space into two portions. The anterior portion con- 
tains the penis and urethra, and is called the perineum. 
The posterior portion contains the termination of the 
rectum, and is called the ischo-rectal region." 

The ischo-rcctal Fossa. This is the space between 
the tuberosity of the ischium and the rectum. It is 
a pyramidal shaped space w T ith the apex directed up- 
ward and the base corresponding to the surface of 
the skin. It is composed of a quantity of fat and loose 
areolar tissue which is very distensable to allow the 
rectum to expand for the passage of fecal matter. 



ANATOMY 49 

There are numerous connective tissue bands that 
divide the fossa into compartments which accounts 
for the fact that pus is not in one large abscess but 
in numerous small ones. The space is crossed by 
numerous blood vessels and nerves but none of them 
are important. Owing to the fact that the connective 



'";,';■ ,' 



1 



"3 



: i . _„i 



Fig. 9. Female perineum. — (Kelley.) 



tissue and fat are continuous from side to side behind 
the rectum, when an abscess occurs in one fossa it is 
very likely to burrow between the levator ani and the 
coccygeal attachments of the external sphincter until 
it gets into the fossa on the other side, forming, when 
the internal opening into the bowel and the two exter- 



50 TREATMENT OF RECTAL DISEASES 

ml openings have occurred, the so-called horse shoe 
fistula. 

The Skin is thick and closely adherent to the under- 
lying fascia. Over the external sphincter muscle, 
scattered bundles of involuntary muscular fibres are 
found which radiate from the interior of the anus. 
This is the corrugator-cutis-ani muscle. By its con- 
traction it raises the skin into ridges radiating from 
the margin of the anus. 



CHAPTER III 

CONSTIPATION. 

As so many rectal diseases are caused by consti- 
pation, while others are kept from recovering because 
of it, thereby retarding the efforts of the surgeon to 
effect a cure, it seems best to describe briefly measures 
for its relief. While I do not wish to go into details 
of cause, it seems necessary to enter somewhat into 
this in order to bring out the best methods of treat- 
ment. 

Constipation at best can scarcely be called a dis- 
ease, but is more properly spoken of as a symptom of 
some other abnormal condition, especially chronic in- 
digestion. It may, however, be the result of other 
causes than ill health, often being simply a habit or 
the effect of sedentary occupations or unsuitable diet, 
or to lack of attention to the calls of nature, as is often 
the case among ignorant persons who do not regard 
the care of their health as of importance. Then again, 
the condition may be inherited ; it is not uncommon to 
find infants who are otherwise in perfect health con- 
stipated from birth ; again, acute causes, as the pain 
of an irritable ulcer ; or mechanical causes, as preg- 
nancy, stricture, tumors, etc., may be the means of 
establishing it. A very common cause, especially 
among females, is the lack of convenience for attend- 
ing to the calls of nature ; they are often awav from 
the vicinity of the toilet-room when the desire is felt, 
or it is situated in a cold or dark place, or so public 
that the natural female modesty causes them to put 

51 



52 TREATMENT OF RECTAL DISEASES 

the matter off until the desire passes away and is no 
longer felt; this being kept up for a long time, nature 
finally rebels, and the sensitive nerves of the rectum 
become blunted and no longer convey the sensation 
to the brain. This part of the process is purely in- 
voluntary, and when felt, should receive prompt at- 
tention, as it is nature's signal that an evacuation is 
desired. From this point on, however, the process is 
under almost complete control of the will and may 
be disregarded, in which case the fecal mass is lifted 
back into the sigmoid, where it remains for another 
twenty-four hours, when it again passes into the rec- 
tal pouch, and nature once more announces her desire 
to get rid of waste matter, as she is always ready to 
do her part, and exacts severe penalties for the disre- 
gard of her laws, and no exception is made in these 
cases. 

From what has already been said, it is at once ap- 
parent that the treatment should consist in removing 
the cause. Sometimes this is all that is necessary, 
but often it will not suffice, as the habit has become 
so fixed that it will require a long time and much 
patience on the part of both the doctor and the patient 
to effect a cure. 

There is probably no one thing so important as 
getting the bowels back into the habit of moving at 
a regular time daily ; the patient should be taught 
that this is the most important event of the day, and 
should never under any conditions be neglected. He 
should be told to exercise in the open air as much as 
possible ; simply a stroll around the block will do no 
good, but a brisk walk of a mile or two every day will 
be of great benefit ; bicycle or horseback riding, boat- 
ing, or anything that will bring all the muscles of the 
body into action, start the blood to flowing more freely 



CONSTIPATION 53 

through the sluggish veins and capillaries, and open 
the pores will often do wonders. Frequent baths with 
brisk rubbing is of benefit, as is also massage, especi- 
ally of the abdomen, following the direction of the 
colon. 

The diet should be carefully looked after, and the 
remarks on page 65 are applicable here. 

Drugs should be used only very sparingly, and 
not at all if it is possible to avoid it; those recom- 
mended as being beneficial in this condition are very 
numerous, and no one need lack for variety. I believe 
that the mild alkaline mineral waters taken morning 
and evening do no harm, even if taken for a long time, 
or until they, with other means, bring about a normal 
condition of the bowels. Many times a glass of cold 
water taken at bedtime, and a hot one containing a 
very small amount of sodium phosphate or magnesium 
sulphate an hour before breakfast, are of benefit. If 
a more decided effect is necessary, the following plan 
has proven very beneficial with me. Begin with the 
minimum daily amount of Fl. Ext. Cascara Sagrada 
required to get at least one bowel movement ; give the 
amount required in three doses, one before each meal. 
Suppose it requires ten drops three times a day to 
produce the desired result ; this is given for a week, 
when one drop is omitted from each dose ; the amount 
is decreased one drop each week until it gets down to 
nothing. If necessary this may be repeated, beginning 
the second time with about one-half the original dose, 
or in the case supposed, five drops. If other measures 
have been carefully attended to, the patient ought now 
to discontinue the medicine entirely. There is a small 
pill on the market having the following formula that 
I have used with success in the way just spoken of, 



54 TREATMENT OF RECTAL DISEASES 

using the proper number of pills instead of the drops 
of Cascara Sagrada. 

Ext. Aloes purificat 1-12 gr 

Ext. Nucis Vom. 1-24 gr 

Ext. Belladonnas 1-100 gr 

Oleoresin Capsici 1-500 gr 

Pulv. Ipecac 1-120 gr 

Misce. Ft. pil. No. 1. 

I think that the above pill is improved by adding 
to it a small amount of Cascara Sagrada. 

The pill spoken of on page 66 is a most excellent 
one if it seems necessary that something should be 
given continuously. 

In cases of pregnancy, where it seems to be neces- 
sary to give something for a long time, aiming to 
keep the patient in condition until after parturition, 
or in chronic diseases, where it is not thought best to 
try to effect a radical cure, the following formula is 
a most excellent one: 

Cascarin 1-4 gr. 

Aloin 1-4 gr. 

Podophyllin 1-6 gr. 

Ext. Belladonna? 1-8 gr. 

Strychnin Sulphat 1-60 gr. 

Gingerine 1-6 gr. 

Misce. Ft. pil. No. 1. 

Sig. Give one or two at bedtime as required. 



CHAPTER IV. . 

HEMORRHOIDS. 

Hemorrhoids or so-called "piles" are tumors, situ- 
ated at the mucocutaneous junction of the anus or 
beneath the mucus membrane of the rectum and com- 
posed of a dilated blood vessel or a mass of dilated 
blood vessels united by connective tissue, or to a clot 
of blood outside the blood vessel caused by a rup- 
tured vein. 

This does not, strictly speaking, include the so- 
called tag of skin, but as they are usually the remains 
of the thrombotic variety or some irritation of the parts 
they would come under the above definition, when 
they first become of sufficient importance to require 
the care of the physician. 

Cause of Hemorrhoids. Nearly everything imag- 
inable has been assigned as the cause of this disease, 
and yet it seems to occur regardless of any apparent 
reason. I have seen persons who were in perfect health 
otherwise, afflicted with the disease in its most aggra- 
vated form, while others who seemed to do everything 
possible to produce an attack escaped entirely. 

Still there are some things that may safely be 
accepted as causes. In the first place we find that 
age has much to do with it as the disease seldom oc- 
curs in early life. Children are not often affected al- 
though it is possible that this might occur. Cases 
are reported in children less than a year old. Many 
things that are known to produce the disease do not 

55 



5G TREATMENT OF RECTAL DISEASES 

occur in childhood, such as menstruation, child-bear- 
ing and the excessive exercise of the genito-urinary 
functions. 

It has been thought that heredity had some in- 
fluence in causing the disease. While I am not able 
to deny that this is so it seems to me that it is 
true in a general way only. If a mother is in poor 
health during her period of gestation and suffers from 
anemia, constipation and the hemorrhoidal . troubles 
that so often accompany this condition, it is only reas- 
onable to think that her offspring may be affected the 
same way to a certain extent, but because a child's 
father or mother had some rectal disease at some re- 
mote period of life is no reason why the child should 
be afflicted in the same way. This is purely a local 
disease and there is no constitutional effect upon the 
system that may be handed down from father to son, 
as there is in syphilis and some other diseases. Where 
hemorrhoids appear in successive generations it is 
more likely that the children have lived in about the 
same way their parents did before them and the con- 
ditions that produced them in the parents have reprodu- 
ced them in the children. I have on more than one oc- 
casion treated father and son and have known the 
disease to have been present in three generations. 

It is generally believed that this disease is more 
frequent in men than women. Men lead a rougher 
life than women and are more subject to severe mus- 
cular effort and are more likely to over eat and drink 
alcoholic liquors to excess, and yet on the other hand, 
women are subject to a monthly engorgment of the 
pelvic organs, and child-bearing is known to be a most 
prolific cause of the disease. So, on the whole, it seems 
to me that the chances are about equally balanced. 
One reason more men seem to be afflicted than women 



HEMORRHOIDS 57 

is because the latter will not seek medical aid unless 
they are in a very serious condition, while men are 
more likely to go to the doctor upon the first appear- 
ance of the trouble. 

There is no doubt that occupation and manner 
of living have much to do in the production of this 
disease. Persons who are constantly on their feet, 
especially if at the same time they are engaged in 
some hard labor, as railway firemen, engineers, etc., 
are very likely to be affected. When this is combined 
with irregular meals we have a most prolific cause of 
the disease. On the other hand, persons who lead a 
sedentary life and are constantly at their desk are 
very prone to the disease because of the lack of. exer- 
cise with its attendant indigestion and constipation. 
Those who habitually gorge themselves with large 
amounts of food and liquor are very likely to have 
hemorrhoids and it is not uncommon with some people 
to have an attack follow a banquet where much rich 
food and drink are taken. 

Probably the most essential cause of the disease 
is an anatomical one. This consists in the erect pos- 
ture of the human being. Man is the only animal who 
stands erect. This posture throws the weight of the 
entire column of blood from the hemorrhoidal veins 
into their terminal portion in the rectum and a con- 
stant dilatation is the result. If the veins were supplied 
with valves, this would relieve this constant conges- 
tion to a certain extent, but there are no valves. The 
veins pass from the peritoneal side of the bowel 
through button-hole like slits to the mucous side about 
a fingers length above the anus and then divide into 
smaller branches and drain the lower end of the bowel. 
This peculiar anatomical condition is no doubt the 
most prominent cause of hemorrhoids, as it may, under 



58 TREATMENT OF RECTAL DISEASES 

certain conditions, such as constipation, pregnancy 
or retro-version of the uterus, shut off the calibre of 
the veins and cause an engorgment and excessive di- 
latation of their lower ends. As the arteries are of 
different construction and do not pass through these 
openings they are not occluded in the way the veins 
are. As a result the blood flows into the parts easily 
but has difficulty in getting out, and dilatation and 
hemorrhoids is the result. 

Classification. In a general way hemorrhoids are 
divided into two general divisions, viz: external and 
internal, and these are each subdivided into two kinds 
as follows: Internal — Venous and Capillary. External 
— Thrombotic and Cutaneous. We often hearofvarious 
other kinds as blind, bleeding, itching, mixed, inflam- 
matory, etc., but they are really all included in the 
above classification. 

By internal we mean those above the sphincter 
muscles and which originate from the superior hem- 
orrhoidal vein, and by external is understood those 
below the sphincter that are from the inferior hemor- 
rhoidal veins. There is a mixed variety which is real- 
ly a combination of the internal and external and need 
not be considered separately. 

Symptoms and Diagnosis. Taking up each variety 
separately we will first consider the internal. 

Capillary Hemorrhoid. These are simply a di- 
lated condition of the terminal ends of the blood ves- 
sels and often if left untreated merge themselves into 
the venous form. While still small enough to be 
called capillary they do not project into the calibre 
of the bowel to any great extent and for this reason 
are difficult to locate. They are really more like a 
naevus or erectile tumor and often have the appearance 
of a ripe strawberry. The covering over the dilated 



HEMORRHOIDS 59 

vessels is so thin that the passage of fecal matter over 
it causes it to rupture and a loss of blood is the result. 

This constitutes practically the only evidence of 
the disease, as there is no pain, protrusion or any other 
symptom except the loss of blood. Often the patient 
is entirely ignorant of the fact that blood is being 
lost and great anemia results which does not yield to 
treatment by iron, arsenic, etc. I have had patients 
who were so w r eak from loss of blood that they could 
scarcely walk alone and who had been treated for 
months by internal remedies with no thought by them- 
selves or by their doctor that the trouble all came from 
capillary hemorrhoids. Although but a small amount 
of blood is passed each day, nature cannot reproduce 
it as fast as it is lost. 

Venous Hemorrhoids. In this form the capillary 
network of blood vessels has disappeared and pro- 
trusion is the chief symptom. It is true that the 
venous variety often bleed but it is from the pressure 
of the temporarily strangulated tumor which is pro- 
truded just far enough to allow the sphincter muscle 
to shut off the return flow and blood is forced through 
the walls of the veins. The patient is usually greatly 
relieved after this bleeding occurs. 

As a rule this form of the disease does not need 
treatment until the tumors get large enough to pro- 
trude, but sometimes there is a train of symptoms that 
are characteristic of the disease before the patient 
realizes the nature of his complaint. Kelsey enumer- 
ates these symptoms as follows : "A feeling of dis- 
comfort in the rectum, and a sensation that it has not 
been thoroughly emptied after stool, which induces 
the patient to sit and strain for a long time ; difficulty 
in micturation ; diminished sexual power and desire ; 
pain in the genitals, loins, and thighs ; and formication 



GO TREATMENT OF RECTAL DISEASES 

in the lower extremities." In case the tumors are not 
large enough to protrude at stool it is often a difficult 
matter to discover them as they recede among the folds 
of mucous membrane and often they cannot be felt by 
the finger or seen through a speculum. Fortunately it 
is seldom that treatment is required unless they pro- 
trude or bleed. There is really only one sure way 
to diagnose this kind of hemorrhoid and that is to 




Fig. 10. Prolapsed internal hemorrhoids. 

have them forced out where they may be plainly seen. 
If necessary an enema of warm water should be 
given which will enable this to be done quite easily. 
There is scarcely any other condition for which this 
could be mistaken unless it might be prolapse. The 
latter comes down around the entire circumference of 
the bowel, making a complete ring, while hemorrhoids 
consist of one or more distinct tumors all more or 
less congested, solid and angry looking. 

Thrombotic Hemorrhoids. This is caused by the 
rupture of a small vein and the extravasation of 
venuous blood into the connective tissue. It often 
comes on without any apparent cause. The patient 
will feel an uncomfortable sensation at the verge of 
the anus and upon examining himself will find a small 
lump which he tries in vain to push above the sphinc- 
ter muscle. If he finally succeeds, he finds that it 



HEMORRHOIDS 61 

will not remain there but at once comes out where he 
first found it. In fact it will neither stay clear in or 
clear out but persists in remaining where it is grasped 
by the muscle, which renders it very painful. In fact 
pain is the essential feature and there seems to be 
nothing that the patient can do or any position that 
he can assume that in any way alleviates the pain. 
If seen soon after it occurs, it will be found to be 
soft, of a bluish black color and very painful. If 
examined a few days later, it will not be quite so 
painful, and will feel like a shot or other hard sub- 
stance beneath the skin. If allowed to take its own 



i 

Fig. 11. A typical thrombotic hemorrhoid. 

course, it will be absorbed and carried away or suppu- 
rate and form a small marginal fistula. 

Cutaneous or Connective Tissue Hemorrhoids. 
These are really fleshy skin tabs and consist of the 
remains of thrombotic tumors that have been allowed 
to absorb, or from some irritation about the edge of 
the anus. The condition is often found after some 



62 TREATMENT OF RECTAL DISEASES 

more serious disease of the bowel higher up. In fact 
it used to be considered a prominent symptom of 
stricture or ulceration of the bowel. It is said by 
some that they are indicative of syphilis. They are 
not of much importance unless inflamed when they 
become quite painful. 

TREATMENT. 

The treatment of the capillary variety consists in 
obliterating the dilated blood vessels and producing 
an eschar instead. Probably nothing accomplishes this 
better than the application of fuming nitric acid. No 




Fig. 12. Tuttle's rectal speculum. Very useful in treating 
capillary hemorrhoids. 

cocaine is needed as a rule, although if the patient 
is nervous or very sensitive to pain, it may be used. 
Dip a glass rod in the acid, and while the spot is ex- 
posed through a speculum, apply the acid, rubbing it 
in well but being careful to not allow it to drop upon 
or touch any other spot. After the acid has been 
applied, put on a solution of soda to neutralize any 
excess that may be present. This causes but little 
pain and requires no after treatment. They may be de- 
stroyed by exposing the bleeding area and applying 
the red hot thermo-cautery. 



HEMORRHOIDS 63 

The best treatment of the thrombotic form is to 
take a small, very sharp, curved knife and make a 
free incision, much the same as would be done if 
opening an abscess, and turn out the clot. This is 
somewhat painful, and if it is desired to do a painless 
operation, dip a needle in pure carbolic acid and touch 
the healthy skin at the margin of the swelling. This 
will anaesthetize a spot through which the hypodermic 
needle may be painlessly thrust just far enough to 
include all the beveled edge, when a drop of cocaine 
solution may be forced in ; after waiting a minute for 
this to have its effect, it is pushed in a little farther 
and more solution injected. In this way the swelling 
may be filled with the solution and opened with abso- 
lutely no pain. After the clot is turned out a pledget 
of cotton should be placed in the wound and left for 
twenty-four hours. It should be examined at this 
time to see that the cotton has not fallen out and a 
new clot taken its place. If this has occured, it should 
be repacked, otherwise it should be syringed out with 
carbolized water, after which it will require no further 
treatment. In case there is a redundancy of tissue, it 
is better to simply lift the tumor from its base with a 
pair of toothed forceps and make an elliptical incision 
around it, entirely removing not only the blood clot, 
but considerable of the surrounding tissue. If this 
is done, two or three fine silk sutures should be put 
in to draw the edges together. By putting them quite 
deep they may be inserted before the tumor is cut 
off and at once tied securely. Two or three days 
later they should be removed. Either of these plans 
will give the very best results, both to patient and 
operator, and the disease will be permanently cured 
in the shortest possible time, which need not exceed 
three or four days. Should the patient refuse even 



64 TREATMENT OF RECTAL DISEASES 

this little operation, there is nothing to do but apply 
lead and opium wash, together with hot or cold 
applications according to which gives the greater com- 
fort to the patient, and wait for nature to absorb the 
clot, which in many cases requires two or three weeks. 
Or, should absorption not occur, wait for a marginal 
fistula to appear, and treat the latter some time in 
the future. 

The treatment of the cutaneous variety consists in 
injecting the tumor with a solution of cocaine, lifting 
it from its base and cutting it off. Should hemorrhage 
be feared, a couple of ligatures may be placed under 
the tumor as directed in the thrombotic pile. Unless 
there is an unusually large number of them, no fear 
of stricture need be entertained, except if they be in- 
flamed, in which case the swelling is deceptive and 
more tissue may be removed than is intended, resulting 
in an excess of cicatricial tissue and contraction. 
Should the patient seek relief during an attack of acute 
inflammation, it is better to use lead water and opium 
or other astringents until the attack has passed, and 
then operate. This operation is easy to perform, is 
entirely painless, and will give the utmost satisfaction 
to the patient. 

THE PALLIATIVE TREATMENT OF HEMORRHOIDS. 

Sometimes it is necessary to treat persons- who have 
piles, by other than operative methods. This is true 
in pregnancy, where operations are not usually needed, 
as the disease will generally disappear soon after par- 
turition ; also in very old, feeble persons, or those who 
have some other chronic disease, it is often best to 
keep them as comfortable as possible without trying 
to effect a radical cure. Much mav be done if the 



HEMORRHOIDS 65 

patient is willing to do his part and carry out fully 
the directions given. The diet should be carefully 
regulated, and no food eaten that will leave a large 
amount of residue to fill the bowel and pass away as 
waste matter ; the general health should be carefully 
attended to, and only food of the most nutritious and 
easily digested character given ; this should contain 
such things as are known to prevent constipation, such 
as fresh fruits, rice, prunes, cereals, vegetables, brown 
bread, meat broths, oyster soup, etc. If necessary, 
a glass of some alkaline mineral water should be 
taken night and morning, not to act as a cathartic, 
but to keep the bowel contents soft and non-irritating. 

I know of no one thing that is of more benefit 
to these people than to have the bowels move the last 
thing before going to bed instead of in the morning. 
The recumbent position allows the blood to flow out 
of the hemorrhoidal veins easily and quickly, thus re- 
lieving the congestion, and bv morning all irritation 
has disappeared, and the day is passed with but little 
discomfort. On the other hand, where the action oc- 
curs in the morning the blood has to be forced in a per- 
pendicular column, which at best is a difficult perfor- 
mance, and the pelvic contents remain congested and 
the piles irritated all day. After the bowels move, 
a small amount of cold water should be injected to 
be sure the rectal cavity is completely empty. Often 
most excellent results are obtained by following this 
with equal parts of water and witch-hazel and retaining 
it. This has an astringent effect upon the dilated veins, 
and sometimes seems almost to be curative, although 
the patient should always be informed that he need 
not expect a radical cure. 

Should there be a decided tendency to constipation, 
medicines of a decidedly laxative character should be 



6G TREATMENT OF RECTAL DISEASES 

given. The following formulas have given me good 
results : 

Sulphur Loti I oz. 

Potass Bitart i oz. 

Pulv. Sennae 4 dr. 

Fl. Ext. Case. Sagrad 2 dr. 

Misc. Sig. Take a teaspoonful at bedtime. 
Also : 

Aloin 1-4 gr. 

Strychnin 1-60 gr. 

Ext. Belladon 1.10 gr. 

Ext. Case. Sagrad 1 gr. 

Misce. ft. pil. I. 

Sig. One or two at bedtime. 

I believe it to be bad practice to be constantly in- 
troducing suppositories into the rectal cavity. They 
are said to "soften the fecal mass" and make it 
"mushy," but when it is remembered that the fecal 
mass is in the sigmoid flexure except for a few minutes 
just previous to defecation, it is hard to see how it 
could be affected by drugs that do not extend more 
than a finger's length above the external sphincter. 
It is true that in some especially old persons the rectal 
cavity is more or less filled with hard fecal matter all 
the time, but this is abnormal, and if washed out with 
cold water, as already advised, after each bowel move- 
ment, it will be empty the greater part of the time. 
In some instances the fecal matter is dry and hard, 
being passed with difficulty and greatly irritating the 
anal canal. In such cases a half-ounce of sweet oil 
injected an hour before the bowels move will do great 
good, not so much from softening the hard lumps as 
from its lubricating properties, by which they are cov- 



HEMORRHOIDS 67 

ered with oil and the mucous membrane is softened 
and their passage made easy. If it seems that a more 
decided astringent action is desirable, an ointment con- 
taining tannic acid may be used through a pile pipe two 
or three times daily. 

After studying this disease for years, I believe that 
the palliative treatment outlined will keep patients who 
suffer from piles in better condition than any other 
with which I am familiar. 

Dilatation. In old chronic cases of internal hemor- 
rhoids it seems a waste of time to expect a cure from 
dilatation of the sphincter muscle as the tumors will 
not in any way be diminished in size and the muscle 
will be weakened and put in a much poorer condition 
to hold the mass up than it was before. The condition 
in which a cure may be expected is in recent cases 
where the tumors are just forming and the irritated 
sphincter muscle grasps them so firmly that great pain 
is caused. Here a thorough dilatation or rather di- 
vulsion of the muscle will bring about a cure for some 
time and often permanently. 

I am endeavoring to perfect a plan whereby this 
may be done in the office with cocaine anaesthesia and 
am able to do it in certain cases quite well but in others 
it is not an entire success. This is by cataphoresis. 
A pledget of gauze is soaked in a 10% cocaine solution 
and wrapped about a specially devised copper rectal 
electrode. (See cut.) The gauze should extend over 
the enlargement so as to affect a portion of the skin 
outside the anus. This is now attached to the positive 
pole of a galvanic battery and a large moist pad at- 
tached to the negative pole and applied to the buttocks 
and about thirty milliamperes turned on and kept go- 
ing for ten minutes. But very little of the cocaine will 
get into the general circulation but the tissues will be 



68 TREATMENT OF RECTAL DISEASES 

saturated with it better than if injected hypodermically. 
Nitrous oxide gas works nicely in these cases but the 
apparatus is expensive and not often needed and most 
physicians do not have it in their office. In case 
neither of the above can be used, chloroform or ether 
are always at hand. As the muscle must be divulsed 




Fig. 13. Copper Electrode for producing anaesthesia of 
the sphincter muscles. 



in case the ligature or clamp and cautery are used, it 
will be well to describe here how to do it. 

By divulsion is meant the stretching of the sphinc- 
ter muscles until they are temporarily paralyzed so that 
any tumors or other abnormal conditions may be 
brought plainly into view. 

It is not the intention to break the muscle and great 
care should be used in this regard. For this reason 
the various dilating instruments are never used by me 
with the exception of a broad bladed bi-valve speculum 
which is used to begin the operation, when my fingers 
or thumbs placed back to back are substituted. In this 
way I can feel the muscle yield and can direct the 
force intelligently and not have to depend upon a steel 
instrument. The force applied should be directed in 
all directions and slowly, the thumbs being changed to 
different quadrants of the anal ring as dilatation takes 
place. If the muscle persists in contracting after the 
thumbs are removed the operation should be continued 
until it ceases to do so. Caution should be used in 



HEMORRHOIDS 69 

doing this operation on old persons or those whose 
muscles are weak as there is a possibility of its causing 
incontinence, although it has never done so in my 
practice. 

THE INJECTION METHOD OF TREATING PILES. 

This method is very much misunderstood by the 
profession, and many think that -it should never be 
used, urging that it may cause sudden death, carbolic 
acid poisoning, emboli, abscess, fistula, great pain, 
etc*. I have never been able to learn of a death as a 
result of this treatment, and persons who make this 
claim have never, so far as I am concerned, been able 
to verify it other than by hearsay evidence. The other 
things such as abscess, etc., are no more apt to occur 
in the practice of qualified men than accidents are in 
the ordinary surgical procedures in the practice of 
the same me::. It is well known that the great surgeon, 
Sir Astley Cooper, lost a patient from hemorrhage in 
a ligature operation for piles, and several others have 
been lost by good operators. I have seen complete 
stricture caused by the too free use of the cautery in 
hemorrhoid operations. I recently came near losing 
a patient from secondary hemorrhage following an 
operation for fistula. These accidents are not the 
fault of the method, but of the operator. I know that 
when this plan of treatment came out there were many 
accidents reported by Andrews, but this was by inex- 
perienced men, and the same is true of any operation 
or new procedure. The first operations for the radical 
cure of hernia were nearly all failures ; now they are 
nearly all successes. So it is not fair to compare this 
method as now done by reputable men with the results 
obtained ten or even five years aq-o. I do not wish t:> 



70 TREATMENT OF RECTAL DISEASES 

be understood as advocating this treatment in all cases, 
but that it has a field of usefulness, and in many cases 
is the very best procedure that can be adopted, is be- 
yond question. I have used it in hundreds of cases, 
and in nearly every instance' with the happiest results. 
Several years ago, in a paper read before the Medical 
Society of the Missouri Valley, I made use of the 
following words, and further experience has given me 
no reason to change my opinion: "Patients suffering 
from internal piles do not, as a rule, consult a physician 




Fig. 13A. Proctoscope, or Sphincterscope, to be used for 
diagnosing piles, and to expose them to view so they 
may be grasped with forceps and drawn down. 



until the tumors have been formed for some time. 
They may have existed for a long time before their 
presence is known by the patient ; but after an unusual 
amount of exertion, or a protracted period of constipa- 
tion, or too liberal indulgence in food or spirituous be- 
verages, they suddenly begin to protrude at stool. 
Now, when this occurs, they will nearly always be 
highly irritated and in a badly inflamed condition. 
Should the sufferer come to vou at this time, he would 



HEMORRHOIDS 71 

not be a suitable subject for the injection plan of treat- 
ment. But most of these patients buy some patent med- 
icine to use until the acute exacerbation is over, and 
then go along pretty comfortably until another attack 
occurs, and each one proves a little more severe than 
the one that preceded it, until the tumors get so they 
protrude at stool. They generally remain more or less 
irritated, with the sphincter muscle highly sensitive. 
But occasionally, in a case of long standing, they will 
lose their soreness, and the constant friction and con- 
gestion will induce an induration of the tumor wall 
with a plastic exudation into the connective tissue be- 
tween the coats of the bowel, and a somewhat hard 
semi-fibrous tumor is the result. The constant, protru- 
sion causes the sphincter to lose to a considerable de- 
gree its contractile power, and they protrude very 
easily. The sphincter also loses its sensitiveness and 
tendency to spasmodic contraction, which is so pain- 
ful. In many cases the tumors are out of the body 
most of the time. These are the cases that are suit- 
able for injection. In a recent work upon rectal sur- 
gery, by Drs. Goodsall and Miles, of St. Mark's hospi- 
tal, London, the following language is used: "In the 
third stage of hemorrhoidal formation, i. e., when the 
piles do not spontaneously return into the rectum, but 
require manual reduction, the prolapse taking place 
again upon slight exertion, such as standing or walk- 
ing, as well as with every act of defecation ; bleeding 
is the exception, a discharge of rectal mucus taking 
its place. When the surface of these piles is examined, 
the mucous membrane will be found to have undergone 
considerable structural change at its lower part, the 
epithelial covering being considerably thickened, so 
as to closely resemble epidermis. This altered mucous 
membrane is very much paler in color than normal, 



72 TREATMENT OF RECTAL DISEASES 

and when dried, its surface does not readily become 
moist again. Moreover, gently rubbing the surface 
will not always cause bleeding, as would occur with a 
pile covered with normal mucus membrane. Micro- 
scopically the epithelium of the altered mucus mem- 
brane is seen to have become metamorphosed, the 
single layer of columnar cells having been changed 
into several layers of stratified epithelium.'' This de- 
scribes exactly the form of tumor to which I believe 
this method adapted. When used in this kind of case, 
and in a proper manner, there will be but little pain or 
other complication, and the cure will be as complete 
as though done with the ligature, provided, of course, 
all the tumors are treated. As more fully illustrating 
my meaning, I wish to describe two typical cases that 
I treated several years ago. 

Case i. Mr. H., a farmer, age about 50, had been 
a sufferer from internal hemorrhoids for several years. 
He had used about all the remedies that he had seen 
advertised, and nearly everything that his friends had 
recommended, with negative results. When he came to 
me, he easily forced into view several large, solid, pain- 
less tumors, such as I have just described. The sphinc- 
ter muscle was greatly relaxed, and the tumors were 
out most of the time. I injected one of the large tu- 
mors and one of the small ones with a fifty per cent 
solution of carbolic acid, and returned them into the 
bowel. No pain was complained of, and I could hardly 
make the gentleman believe that I had done anything. 
In about three weeks I injected the remaining tumors 
with the same result. These tumors have never been 
seen or heard from since, and nearly ten years have 
passed since the operation. There was no pain or in- 
convenience of any kind, neither was the patient hin- 
dered in the least from attending to his ordinary work 



HEMORRHOIDS 73 

about the farm. This was a typical case for the injec- 
tion plan, and the most happy results were obtained, 
but such cases are not the class most often seen. In 
fact, such strikingly typical cases are rather rare. I 
wish now to describe one that is just the reverse of 
the above. 

Case 2. Mr. W., also a farmer, age about 35, a 
neighbor of the foregoing, hearing how easily Mr. H. 
was cured, came to me, and upon examination, I found 
several highly sensitive tumors grasped by an irritated 
sphincter that was greatly given to spasmodic action. 
He would hear of no other treatment than that of in- 
jection, as had been done upon his friend. I explained 
to him that the cases were not the same, and that the 
operation in his case would be very painful ; but it 
was that or nothing with him, and so, much against 
my judgment, I operated by the injection method. I 
injected two medium size tumors the first time, and in- 
tended operating upon the others later. He still has 
the others, as I never had another opportunity to treat 
them. In a few hours after the operation he began to 
have pain, and it continued until it became terribly 
severe, and required large doses of morphine. His 
suffering was very great and lasted for a long time. 
This is an extreme case, and should not have been 
treated in this way, at the time that it was. A week 
or two of preparatory treatment might have put the 
patient in proper condition for this method, but it 
would have been better to have operated upon him by 
the ligature. 

METHOD OF OPERATING. 

I do not think it best to disturb the patient's bowels 
by giving a cathartic unless he is constipated. If the 
preparatory treatment already described has been 



74 TREATMENT OF RECTAL DISEASES 

given, nothing further is needed, otherwise the diet 
may be limited for a day or two, and an enema of hot 
water used two or three hours before coming to the 
office. Have the patient lie on the left side, and if 
he can do so, strain the tumors outside the sphincter 
muscle. In case he cannot do this, an enema of warm 
water should be given, which will bring them plainly 
into view. I usually put some cosmoline on the expo- 
sed tumors and mucous membrane to protect them 
from injury in case any of the acid accidentally runs 
over the outside. Having now filled the syringe with 
a fifty per cent solution of carbolic acid with equal 
parts of glycerine and water, the needle is thrust with 
a quick but gentle motion into one end of the long axis 
of the tumor and the point pushed to the opposite 
side, being very careful not to puncture the farther 
wall, as the medicine will run out of the opening made 
and do fio good. Now, as the needle is being slowly 
withdrawn, the fluid is injected drop by drop.. As 
this is being done a pale bluish color is seen to creep 
over the surface, and this is evidence that enough has 
been injected. 

Should the tumor be quite large, the needle, before 
being withdrawn, may have to be again pushed in at 
an acute angle to the first puncture, and a little of the 
fluid forced into the tissue at each side not previously 
reached. The injection should be made very slowly 
in order to allow the medicine to diffuse itself as far 
as possible through the tissues, and a drop should be 
deposited just inside the puncture before the point 
of the needle is withdrawn in order to cauterize the 
opening and prevent the escape of the fluid. • As the 
needle is quickly withdrawn, a pledget of cotton dipped 
in Monsel's solution is placed over the opening and held 
there for a short time to prevent the escape of the 



HEMORRHOIDS 75 

solution. Xot more than one large tumor or two small 
ones should be treated at one time. It is best to operate 
upon the small tumors first, as they are more easily 
gotten at when held out by the large ones than they 
will be after the larger ones are removed. It is also 
easier for the patient, as the small tumors take up some 
room and the swelling is considerable in the large 
tumors, and the more space they have to expand the 
less pain will be experienced. The tumors are now 
well oiled and replaced within the bowel. This can be 
better done by the patient than by the doctor, as he 
has learned by experience how to go about it. The 
bowels should not be allowed to move for two or three 
days, and if necessary, a pill of camphor and opium 
should be given at such intervals as will prevent the 
desire to go to the stool. This will not only bind up 
the bowels, but will relieve any pain that may be pres- 
ent. Should the bowels not move when it is desired 
that they should do so, a light laxative should be 
given ; often a Seidlitz powder will be all that is neces- 
sary, or a small dose of castor oil, or broken doses of 
calomel. When the desire for an evacuation is felt, 
instruct the patient to inject into the bowel an ounce of 
sweet oil, and the evacuation will be painless. I am 
not in favor of introducing suppositories of opium and 
belladonna into the bowel, as they only act as a foreign 
body, and the only anodyne effect is from the absorp- 
tion of the opium, which takes place to better advan- 
tage in the stomach. After the first treatment, or 
where one or more large tumors are treated, the patient 
should refrain from active exercises and remain at 
least part of the time in the recumbent position. Still, 
I have operated upon quite large tumors and had the 
patient go at once to hard labor ; one worked the nexl 
day at digging a well, another at laying brick, and ? 



76 TREATMENT OF RECTAL DISEASES 

third at sawing wood ; this was done, however, contrary 
to my orders. The second operation should not be done 
for about two weeks, or possibly sooner, if all soreness 
has disappeared. The patient may not now be able to 
force any of the tumors into view, in which case the 
work will have to be done through a slide speculum. 




Fig. 14. Slide Speculum for injecting piles, treating ulcers, 

etc. 



In this event an especially made needle about four inch- 
es long should be used. With these exceptions the in- 
jection will be made in the way already described, but 
great care must be exercised not to force the medicine 
under the tumor instead of into it. This accident is 
what causes abscesses, fistula, pain, etc., and should 
be carefully avoided. 

The reason that this method is said to be only 
palliative and not curative is that the tumors are not 
all reached, and six months or a year later one or more 
that were left become enlarged and prolapse. This 
is often the fault of the patient, as after one or two 
tumors are removed, he will feel so much better that 



HEMORRHOIDS 77 

he will not return for further treatment. For this 
reason I always warn patients that there is a possibility 
that one small tumor might possibly come down later 
and have to be removed, but that it will not be a return 
of the disease, and is easily and quickly remedied. 

FORMULAS FOR INJECTION METHOD. 

The following - formula is the one used more often 
than any other, and contains the essential ingredient 
of them all, viz., carbolic acid: 

Carbolic acid I dr. 

Glycerin I dr. 

Aqua Dest 2 dr. 

Misce. 

Dr. Agnew of San Francisco recommends the fol- 
lowing, and has been used in my practice with good 
results : 

Plumbi acet. "| 

Sodii biborate J 

Glycerin i oz. 

Let this stand twenty minutes in a warm water 
bath. After twenty-four hours add one full ounce of 
crystalized carbolic acid and two drams of distilled 
water. The doctor also adds that "some make no al- 
lowance, in attempting to give my formula, for the in- 
crease in bulk of the glycerine occasioned by the ad- 
dition of the half-ounce of solids, and direct that the 
ounce of carbolic acid be added to the full amount of 
the glyceride of lead and borax when made. By this 
inadvertence not much over thirty-five per cent of car- 
bolic acid is obtained. After trying the acid in vary- 



78 TREATMENT OF RECTAL DISEASES 

ing strengths, and watching its effects, I have conclud- 
ed that not less than fifty per cent solution should be 
used." 

The following formula is one that was used for 
years by a traveling specialist. He sold the formula 
with directions for use for one hundred dollars. It 
was given to me by a man who paid fifty dollars for 
it: 

Carbolic acid 4 dr. 

Plumbum acetat 1 dr. 

Salicylic acid 30 gr. 

Cocain mur 10 gr. 

Aqua dest. . 

* . y aa, q. s. it 1 oz. 

Glycerin 

Misce. This should be used according to direc- 
tions previously given. 




Fig. 15. O'Neill's rectal speculum for injecting piles, treat- 
ing ulcers, etc. 



NOTES ON THE INJECTION METHOD. 

Never inject piles that are inflamed or irritated. 
If they cannot be put in a quiescent state, use the liga- 
ture or clamp and cautery. 



HEMORRHOIDS 79 

Never inject more than one large or two small 
tumors at once. 

Always have the intestinal canal, and especially the 
colon, unloaded before operating, and then bind up 
the bowel for two or three days. 

Never use a weaker solution of carbolic acid than 
twenty-five per cent. The object is to cauterize the 
tumor and absolutely destroy it, and this requires the 
stronger solution. A weak solution will often set up 
an inflammation that should never occur. 

Do not operate the second time until the soreness 
has disappeared from the first operation. 

If the directions given in the preceding pages are 
followed carefully, a cure may be expected in all suit- 
able cases, which will constitute a majority of those 
that come for treatment, but the remainder would 
better be operated upon by the ligature or clamp and 
cautery. 

In this, as all other minor operations, it is the atten- 
tion to technique and minor details that counts for 
success or failure, and unless the physician is willing 
to take the trouble to give attention to these, he will 
not be successful, no matter what method he uses. 

Use great care not to inject the fluid under the 
tumor instead of into it, otherwise complications may 
be expected. 

Opiates are as a rule not needed, but should they 
be required, give camphor and opium pill, or morphine 
hypodermically, and make hot applications to the 
anal region ; the pain, as a general thing, is of short 
duration, and does not in any way interfere with the 
cure any more than it does in other methods of operat- 
ing. 

The odor that is often noticable as the destroyed 
tumors come away is not the odor of sloughing tissue, 



80 TREATMENT OF RECTAL DISEASES 

but is due to the admixture of intestinal gases with the 
broken down and disintegrating mass as it is being 
thrown off from the surface of the bowel. 

OTHER METHODS OF CURE. 

OPERATION WITH CONTINUOUS SUTURE CLAMP. 

Another way of operating upon internal piles is 
the following, and it is adapted to any case that is suf 
ficiently developed to allow the tumors to be prolapsed 
so that they may be grasped with a pair of forceps. 
This is also one of the very best methods of operating 
upon the mixed sort of piles where the whole mass, 




Fig. 1G. Method of operating with Dr. Mason's continuous 
suture clamp. 

both internal and external, can be grasped in the jaws 
of the forceps. First, saturate a piece of cotton in a 
ten per cent solution of cocaine, and by the aid of a 
small tubular speculum, insert it into the bowel, letting 
it extend from the rectal pouch to the external sphinc- 
ter. Allow this to remain for about ten minutes, and 
it will partially remove the sensibility from the tumors 
so that they may be handled without pain. Now, either 
have the patient strain them out, or by means of a 
proctoscope, or with a slide speculum and forceps, 
draw them to the outside, taking the large one first. 
When the tumor has been exposed to view, seize its 
base, just tight enough so it will not slip, but not so 



HEMORRHOIDS 81 

tight as to cut off the circulation, with the author's con- 
tinuous suture clamp. Xow inject the tumor as full as 
it will hold of a four per cent solution of cocaine. After 
allowing this to remain for a minute or two, the clamp 
is closed as tightly as possible, and the tumor cut off 
close to the upper surface. A medium size catgut is 
now threaded into a curved needle and passed through 
under the extreme upper end of the clamp, anda second 
stitch is taken so that it includes the first one in its 
grasp and serves to hold it from slipping, or a perfora- 
ted shot may be clamped on the upper end which will 
answer the same purpose. The needle is then passed 
under and over the clamp at intervals of about a quar- 
ter of an inch until the lower end of the cut tissue is 
reached, being careful not to draw the ligatures tight. 
(See Fig. 16.) The upper end of the ligature is now 
seized with a pair of artery forceps, the clamp removed, 
and tension made upon the lower end af the ligature, 
which will draw the stitches into place and securely 
close the wound. A knot is made in the lower end or a 
shot clamped on, and the remainder of the ligature cut 
off. All the tumors may be operated upon at one time, 
or if preferred, they may be taken at intervals of a 
couple of weeks. This is one of the most satisfactory 
operations that I know of, as it is perfectly safe, has no 
complications, is adapted to any form of pile, provided 
only that it can be reached, and can be performed by 
any physician without assistance, and with but little 
trouble. If but one tumor is to be operated upon, the 
patient need not go to bed, or even stop his ordinary 
work. There will be but little pain, and an opiate is 
seldom required. The bowels should not be confined, 
but allowed to move regularly, and the patient instruc- 
ted to bathe the parts often with warm carbolized 
water. 



82 TREATMENT OF RECTAL DISEASES 

OPERATION WITH NOTCHED CLAMP. 

Another operation that has proven satisfactory is 
performed exactly as the one that has just been de- 
scribed, except that a clamp is used with a notched edge 
extending one-eighth of an inch above the jaws, 
through which ligatures are passed, and each tied 
tightly, after which the clamp is removed. (See Fig. 
17.) Either of these gives a clean, neat, surgical wound 




Fig. 17. Showing method of operating with the author's 
notched clamp. 

that is securely protected from hemorrhage, and which 
almost always heals by primary union. As the liga- 
tures are catgut they need not be removed, but in 
operations where they can be easily reached, I prefer 

silk. 




Fh 



18. Appearance of parts after continuous suture or 
notched clamp operation on hemorrhoids. 



Operation by Ligature. 



Thi 



is the oldest 



method of treating internal hemorrhoids that is known 
to surgery and is one of the very best. Probably more 



HEMORRHOIDS 83 

specialists in this line use it than any other method. It 
causes somewhat more pain than some other methods 
but no one can question its safety, efficiency, or the 
permanency of the cure if properly done. 

My method is about the same as that described by 
Allingham. I think the bowels should be pretty well 
cleared before the operation and, to accomplish this, a 
good cathartic should be given the second night previ- 
ous to the operation and followed by liberal doses of 
salts the following day. The evening before the oper- 
ation one or more large, .hot enemas should be given 
to clear the colon of all. fecal matter. A sufficient 
number should be given so that the water returns clear. 
At bed time the patient should have a hot bath and un- 
less there is some contra indication, a pill of camphor 
and opium which will stop the peristalic action of the 
bowels and give a good night's rest. But little water 
should be given just previous to the operation and the 
bladder should be emptied just before going to the 
operating room. I am opposed to starving patients 
for a week before operating as is sometimes done, for, 
if they are at all weak, it is a severe shock and puts 
them in poor condition for the operation. If plenty of 
good nourishing food such as milk, eggs, beefsteak, 
etc., is given up to the time of the first cathartic and 
then reduced to about one third of the previous 
amount, the patient will be in good condition. 

The morning of the operation, no enema should 
be given or in fact anything done except to empty the 
bladder before the patient is brought into the operating 
room. In exceptional cases, if the patient is weak, I 
allow them a small cup of coffee or broth, provided it 
is taken not less than an hour before the operation. 

The patient is now anaesthetized, placed on his back 
with the thighs well flexed on the abdomen and the legs 



84 TREATMENT OF RECTAL DISEASES 

well flexed on the thighs and held in place by leg 
holders. I like this position better than on the side, 
but when operating where a proper table is not to be 
had, the Sims position is satisfactory. Having now 
dilated the sphincters, as previously described, the low- 
est tumor is grasped and with a pair of sharp scissors 
divided from below so that it is attached by the vessels 
and mucous membrane only. There is no danger in 
this as all the vessels large enough to bleed seriously 
are in the upper part of the tumor. A stout ligature 
is now placed around the remaining portion and tied. 
Each tumor is in turn treated in the same way. In 
case a tumor is very large a double ligature should 




Fig. 19. T forceps, to be used for grasping hemorrhoidal 
tumors. 



be passed through its center by the aid of a needle 
after which the needle is cut off and each half of the 
ligature tied around the corresponding half of the 
tumor. For the large tumors, ligatures of plaited 
silk should be used and it should be strong enough so 
that it cannot be broken by pulling. Smaller sized 
tumors require smaller ligatures and care must be 
exercised that sufficient force is not used to make the 
thread cut the base of the tumor entirely off. After 
all have been tied, most of the tumor should be cut 
away leaving only enough to be sure the ligature will 
not slip off. A stream of water is now run over the field 



HEMORRHOIDS 85 

of operation to see that there are no bleeding points 
and a little sterile gauze packed about the stumps of 
the tumors as they recede above the sphincters. I like 
this better than a tube as it checks all oozing and does 
not cause any pain. A pad and T bandage should now 
be applied, the patient given one fourth grain of mor- 
phine and put to bed. 

On the following day the outside pad should be 
changed but the gauze put among the ligatures 
should not be removed but allowed to come away with 
the first bowel movement. A dose of castor oil should 
be given the third day and repeated as found necessary 
until the bowels move. No more should be given until 
the patient gets up. Many male patients are unable 
to empty their bladder after this operation. If the 
caution previously given, to not give them any water 
for a few hours previous to the operation and then not 
allow them to try to empty the bladder for from twelve 
to twenty hours, is observed, they will generally suc- 
ceed, but if they try and fail, the catheter will have to 
be used and in some cases it will be necessary to use 
it in spite of all precautions. I think it all right for 
the patient to get on his feet to empty the bladder the 
first time, as, often they can succeed in this way, where 
they could not while lying down. It is also just as 
well for them to use the commode for the first bowel 
movement and if an ounce or two of warm oil is in- 
jected into the bowel just previous to the movement, 
there will be but little if any pain. It is always best 
to inject a pint of warm boracic acid solution after the 
bowels move to wash out any remaining fecal matter 
and clotted blood. As a rule, my patients do not re- 
ceive more than one or two doses of morphine but, if 
it is necessary, I do not hesitate to give enough to keep 
them comfortable. 



86 TREATMENT OF RECTAL DISEASES 

The ligatures will come away in from five to 
eight days and about this time a little blood may be 
passed but it should cause no alarm as it will soon 
cease. Occasionally a ligature may not be tied tight 
enough to destroy the stump and will not come away 
without assistance. Should this occur, it may be 
carefully exposed through a speculum and removed. 




Fig. 20. Galvano cautery. 

Clamp and Cautery Operation. As Kelsey is the 
most prominent advocate of this method, I will give 
his description of the operation in his own words. The 
preparatory treatment is the same as already described. 

"As a rule the patient is etherized, in order to per- 
mit a free dilation of the sphincters. The tumors are 
next seized and removed one by one. No speculum is 
necessary for this, but if one be used the large Sims 
rectal speculum is the best. The tumor is seized with 
forceps and held out of the anus, while the base at the 
juncture of the skin and mucous membrane is divided 
as in the ligature operation, and the clamp applied 
to what remains of the pedicle in the sulcus thus made. 
The forceps are next detached, the tumor cut off with 
the scissors (but not so short but that a good, firm 
stump remains), and the cautery is then taken from the 
assistant, whose sole duty it should be to have it always 
ready, and applied thoroughly to the stump of the 



HEMORRHOIDS 87 

hemorrhoid. No haste should be used in this step of 
the operation. The pedicle should be thoroughly 
charred with the platinum at a red heat. 

''When this has been done the clamp may be loos- 
ened, without being removed, to see if any vessel in 
its grasp is still inclined to bleed ; and if a bleed- 
ing point appear, it is again tightened and the 
cautery is again applied. Thirty seconds is an 
abundance of time for each tumor. The secret of 
success in this operation is found just here. If all the 
cut surface is thoroughly cauterized while the clamp is 




Fig. 21. Sims' rectal speculum, as modified by Van Buren. 
If any speculum is needed this will Tie the most satis- 
factory in the cautery operation. 



on, there can be no hemorrhage ; but if more surface is 
cut than is cauterized, hemorrhage may reasonably be 
expected and the operator is to blame. Thoroughly 
cauterize the entire incision, except the initial one made 
before the clamp is applied, and trust nothing to the 



88 TREATMENT OF RECTAL DISEASES 

clamp or to nature, is the advice I always try to impress 
most strongly upon those studying this operation. 

"When all the piles have been removed, the stumps 
will naturally retract within the sphincter and no dress- 
ing will be necessary. 

''The thing most difficult for the unpractised oper- 
ator to understand is at just what point to apply the 
clamp ; and this can best be learned by experience, as 




Fig. 22. Clamp for cautery operation on hemorrhoids. 

it really constitutes the delicate point in the operation. 
There is no difficulty when the tumor is an internal 
one arising fairly from the mucous membrane above 
the sphincter, and not involving the skin of the anus. 
In such a case the clamp does not implicate the muco- 
cutaneous junction at the anus, and removing too little 
tissue will not leave unsightly and annoying tags of 
skin, nor will removing more than is necessary result 
in cicatricial contraction to a serious extent. But 
where the margin of the anus tends to roll over, con- 
siderable experience is necessary to learn just how 
much tissue to include in the clamp. 

''When it is necessary to divide the skin of the anus 
with the scissors before applying the clamp, there will 
be a little bleeding, which is easily stopped by a com- 
press and bandage ; but when the clamp is applied only 
to parts covered by mucous membrane, and used with- 
out any preparatory cutting, the operation is almost 
bloodless, and under anv circumstance it is unneces- 



HEMORRHOIDS 89 

sary to soil more than a single towel. This a great 
desideratum in cases of enfeebled patients, besides 
enabling the operator to have his wounds perfectly dry 
without the use of any lint or other dressing. 

"No dressing of any sort is necessary after the clamp 
operation, except a pad of gauze covered with vaseline, 
and a T-bandage applied for a few minutes to arrest 
oozing from the preliminary incisions in the skin. If 
the patient seems to be doing well and complains of no 
untoward symptoms, the parts need not be examined 
for ten days, and all that is required is cleanliness to 
the wound. 

"The bowels should be confined for forty-eight 
hours, and about thirty-six hours after the operation — 
in other words, at night of the following day — they 
should be encouraged to act by a slight laxative, either 
a pill or a saline. A single dose will generally be suffi- 




Fig. 23. Gant's clamp for cautery operation on hemor- 
rhoids. 



cient, and when the time comes for the bowels to move, 
an enema of water should be thrown into the rectum 
to facilitate the passage. In this way an almost com- 
plete clearing out of the rectum is secured on the sec- 
ond day. The patient dreads this first motion, but is 
agreeably disappointed, often being surprised that he 
has much less pain than his hemorrhoids caused him 
in each passage before they were removed." 



90 TREATMENT OF RECTAL DISEASES 

Electrolysis. Good results may be expected in un- 
complicated cases by the use of electricity. The 
tumors are brought into view and two or three ordi- 
nary sewing needles mounted in a suitable holder and 
attached to the negative pole of the galvanic battery 
are thrust into each one separately after which the 
positive pole is placed on the buttocks and a current of 
ten to twenty milliamperes turned on. After a few 
minutes bubbles of hydrogen gas will be seen escaping 
around the needles. After this occurs to a well marked 
degree the current is turned off and the needles re- 
moved. As a rule about five to ten minutes is long 
enough to keep the current on. One application to 
each tumor is generally sufficient but if very large it 
may be required twice. The tumors do not slough but 
slowly shrivel up and disappear. 



CHAPTER V. 



ABSCESS. 



The perianal, rectal, and immediate surrounding 
tissues, are the seat of suppuration more often than any 
other region of the body. The anatomy of the parts 
is such that pus once formed burrows easily along the 
coarse muscular fibres and spreads over a large area 
because of the loose connective tissue so plentiful in 
this region. Pus always goes along lines of least re- 
sistance and if this happens to be the mucous mem- 
brane of the bowel, as is usually the case, the abscess 
will open into the bowel and later it will work its way 
to the outside and open spontaneously or be opened by 
the surgeon. In either case a complete fistula is the 
result which will require operation later. Practically 
every fistula is the result of a previous abscess. Of 
course there are some few exceptions to this, as a 
fistula might result from a surgical operation or a 
punctured wound but these are accompanied by pus 
formation so that the rule would hold good. 

Etioligy. Any condition favoring the invasion of 
bacteria, such as a lowered state of health or a weak- 
ened vitality of the parts locally. A local lesion, such 
as ulceration, fissures, wounds, tears, or a disintegra- 
ting pile tumor, or new growth, may open the way for 
infection and the formation of pus. Traumatism either 
from within or without may be the source of infection 
or start a small point of inflammation that may devel- 
ope into an abscess. I have removed spicula of bone and 
pieces of wooden tooth-picks that had passed through 

91 



92 TREATMENT OF RECTAL DISEASES 

the intestinal canal and caused the inflammation and pus 
formation. When the source of the disease originates 
in the rectum, the abscess almost invariably results in 
a complete fistula. Tubercle bacilli and other pyogenic 
agents known to exist in the intestinal canal are the 
cause of suppuration in many instances. It has been 
proven beyond question that the tubercle bacilli may 
pass unharmed through the stomach and bowels until 
the rectal cavity is reached, where they may, by com- 
ing in contact with an abrasion of some kind, start an 
abscess. The gastric juice will arrest their action but 
the alkaline intestinal fluids will at once restore it. 
Other pus producing organisms that are common to 
the colon may cause the disease ; of these the most com- 
mon are the baccillus coli communis, the strepto-coccus 
pyogenes, and the staphylo-coccus pyogenes. In addi- 
tion to the above causes operating from within, there 
are many that produce their effect from without, as 
kicks, falls, blows, or traumatism of any kind, or from 
surgical operations, the improper use of strong caus- 
tics in treating hemorrhoids, or by infection through 
lesions around the external margin of the anus. Tut- 
tle thinks that a hsematoma may form by the rupture 
of a small blood vessel caused by forcible divulsion of 
the sphincter muscle and infection take place, causing 
an abscess. 

In addition to the local causes mentioned, the con- 
stitutional condition of the patient has a good deal to 
do with the suppurative process. A person who is in 
perfect health has greater power of resistance than one 
whose tissues are weakened by disease. If the whole 
system is run down and the power of resistance is 
small, the ability to resist invasion by infectious germs 
is also small. There is another condition that has 
seemed to me to invite abscess formation in this region 



ABSCESS 93 

and that is the plethoric individual, the man who works 
little and eats much and whose tissues are constantly 
overburdened with the products of digestion and tissue 
building elements. Any injury received by the person 
in this condition, although he may seem to be in good 
health, will cause the tissues to break down and sup- 
purate. 

Varieties. It is a difficult matter to classify the 
different varieties as regards location but the follow- 
ing seems to me to about meet all the requirements. 

i. Subcutaneous or marginal. 

2. Ischo-rectal. 

3. Submucous. 

4. Pclvi-rectal. 

In addition to the above we may have an abscess 
in the prostate, urethra, or from disease of some 
organ or bone far from the region under discussion. 

Subcutaneous or Marginal Abscess. These occur 
around the margin of the anus and are due to the 
suppuration of a thrombotic hemorrhoid or to the in- 
fection of some one of the many glands or follicles 
near the lower edge of the external sphincter muscle. 
An infected fissure may be the starting point, or any 
small tear or bruise which may allow infectious agents 
to enter the circulation. These abscesses are in- 
clined to burrow away from the rectum rather than 
towards it and in many cases a fistula does not result ; 
but as a rule fistula follows this form of the disease. 

Ischo-Rcctal Abscess. This is what is generally 
known as the perirectal abscess and occurs in the ischo- 
rectal space on one or both sides of the anus. This 
space is filled with loose connective tissue and is 
poorly supplied with blood vessels, thus favoring sepsis 
and the formation of pus. It is entirely hemmed in 



94 



TREATMENT OF RECTAL DISEASES 



with fascia so that considerable resistance is offered to 
the further extension of pus. For this reason when 
pus is formed on one side it often passes behind the 




Fig. 24. Diagrammatic representation of an ischo-rectal 
abscess. A, mucous membrane; B, submucous tissue; 
C, circular muscular fibres; D, longitudinal muscular 
fibres; E, pelvi rectal space; F, levator ani; G, ischo- 
rectal fossa; H, integument; I, tendinous insertion of 
logitudinal muscular fibres; J, deep portion of external 
sphincter; K, superficial portion of external sphincter; 
L, interval between internal and external sphincter; 
M, internal sphincter; X, the abscess cavity. — Goodall 
and Miles. 

rectum between the attachment of the levator ani and 
the ano-coccygeal ligament and gains access to the 
ischo-rectal space on the opposite side thus forming 
what will later become a complex or horse shoe fistula. 
As the space immediately behind the rectum is the 
weak point or outlet for the flow of pus from the fossa, 
so also, it is the weak point through which pus burrows 



ABSCESS 



95 



into the cavity of the bowel, thus making the internal 
opening, while the two external openings, one in each 
ischo-rectal fossa, occur later, thus forming a typical 
horse shoe fistula. Occasionally pus may burrow an- 
teriorly to the anus and form an anterior horse shoe 
fistula, but this is not common. In case it does do so 
it is more superficial than when it goes posteriorly and 
usually follows the raphe of the perineum and opens 
somewhere between the anus and scrotum or vagina 
or, in some cases, into the vagina. 

Submucous Abscess. This variety is found in- the 
submucous tissue between the muscular laver and the 




Fig. 2f5. Submucous Abscess. A, mucous membrane; 3, 
submucous tissue; C, circular muscular fibres; D, longi- 
tudinal muscular fibres; E, pelvi-rectal space; F, leva- 
tor ani; G, ischo-rectal fossa; H, abscess cavity; I, 
internal sphincter; J, interval between internal and 
external sphincter; K, external sphincter; L, deep por- 
tion of external sphincter; M, insertion of longitudinal 
muscular fibres; N, integument. — Goodsall and Miles. 



9G TREATMENT OF RECTAL DISEASES 

mucous membrane. It is usually on one side only and 
has a tendency to burrow downward and open at the 
anal margin, or it may break in the bowel with the 
opening so high that it is found with difficulty. This 
is the form in which failure is often met with in fistula 
operations because of the fact that the abscess breaks 
both in the bowel and on the outside so far below its 
upper end or point of origin that when the tissues be- 
low the fistula openings are cut it leaves the main part 
of the abscess untouched and pus continues to form. 
This will be discussed further under fistula. 

Pclvi-Rcctal Abscess. This form of abscess originates 
above the levator ani muscle and below the reflection 
of the peritoneum. They may extend above the peri- 
toneum. They are caused by some affection of the 
bladder, urethra prostate, uterus or broad ligament. 
In women they are called pelvic abscesses and may be 
opened through the vagina. The connective tissue of 
the broad ligaments, meso-rectum prostate and bladder 
are all continuous and if pus forms in almost any region 
of the pelvis, it naturally gravitates to the superior 
pelvi-rectal space. Injuries to the bowel wall on the 
inside above the sphincter muscle will cause this form 
of abscess. This may occur as the result of foreign 
bodies swallowed, as fish bones etc., or it may be the 
result of ulceration or stricture. This form of abscess 
is chronic and will often wall itself off from the peri- 
toneal cavity and work its way downward, sometimes 
forming a connection with the ischo-rectal fossa and 
giving the appearance of being limited to that cavity 
or it may burrow around the bowel and open in two 
or more places, giving the appearance of being a horse 
shoe fistula when it finally opens on the outside. 

Symptoms and Diagnosis. In the subcutaneous 
abscess the symptoms are much the same as those cf 



ABSCESS 



97 



a boil. There is in this the symptoms usually found 
where pus is forming, viz : heat, redness, pain, and 
swelling. The pain in this variety is especially severe 
as it is just at the margin of the anus where it is to a 
certain extent in the grasp of the sphincters. There 




Fig 2G. Digrammatic representation of a pelvi-rectal ab- 
scess. A, mucous membrane; B, submucous tissue; 
C, circular muscular fibres; D, longitudinal muscular 
fibres; E, pelvi rectal space; F, levator ani; G, ischo- 
rectal fossa; H, integument; I, tendinous insertion of 
the longitudinal muscular fibres; J, deep portion of 
the external sphincter; K, superficial portion of ex- 
ternal sphincter; L, interval between the internal and 
external sphincter; M, the internal sphincter; X, the 
abscess cavity. — Goodsall and Miles. 



is a feeling of fullness and throbbing which is intensi- 
fied by walking or sitting. On spreading the nates 
apart and at the same time requesting the patient to 
strain down, the swelling may be easily seen. It could 



98 TREATMENT OF RECTAL DISEASES 

scarcely be mistaken for anything else unless it might 
be a thrombotic pile ; but as an abscess is usually a 
bright red while the former is dark blue or black, the 
mistake is not likely. Even should such a mistake be 
made it would not matter as in either case the treat- 
ment would be by incision and in one case pus would 
be evacuated while in the other a clot of blood would 
be turned out. In the ischo-rectal abscess there are 
much the same symptoms only they are intensified and 
there may be some constitutional symptoms, especially 
in the early stages. Should the abscess burst, 
especially if it be in the bowel, all the symptoms are 
relieved and the patient thinks he is over with it for 
good ;but in this he is mistaken, for it will refill several 
times and the symptoms will all be repeated before it 
finally settles down to be a fistula. As a rule there is 
no especial difficulty in making a diagnosis, as the 
symptoms of pain, heat, redness, and swelling are too 
evident to be mistaken for any other condition. How- 
ever, if seen early, before the pus has come near the 
surface, redness and swelling may be absent. , The 
finger should always be introduced into the bowel as 
by this means much additional information may be ob- 
tained as to the extent of the suppuration and the 
likelihood of its immediate rupture into the bowel. 
Great caution should be exercised that the examining 
finger does not cause it to rupture, as this must if pos- 
sible be avoided. 

In the submucous variety the chief symptom is 
pain during and following a bowel movement. This 
might be mistaken for the pain of a fissure but it is not 
of the same character and is higher in the bowel than 
the latter. The pain of a fissure is an ache while the pain 
of a submucous abscess is throbbing, sharp and lanci- 
nating. If rupture has taken place inside the bowel there 

0* J 



ABSCESS 



99 



will be a discharge of pus at stool and upon examina- 
tion the finger will be found smeared with pus. The di- 
agnosis of the pelvi-rectal abscess is more difficult than 
any of the other forms. Here the diagnostic symp- 
toms of pus formation are not present, or at least not 
prominent. Because of the abscess being so high in 
the pelvis there is no local heat, redness, or swelling 
and while there may be pain of an acute character, it 
is not localized to the rectal region but is ill defined 




Fig. 27. A Pelvi-rectal abscess which has invaded the 
ischo-rectal fossa. A, mucous membrane; B, sub- 
mucous tissue; circular muscular fibres; D, longitudi- 
nal muscular fibres; E, pelvi-rectal space; F, levator 
ani; G, ischo-rectal fossa; H, integument; I, tendious 
insertion of longitudinal muscular fibres; J, deep por- 
tion of external sphincter; K, superficial portion or 
external sphincter; L, interval between internal and 
external sphincter; M, internal sphincter; X, abscess 
cavity; XX, its extension into the ischo-rectal fossa. — 
Goodsall and Miles. 

LrfC. 



100 TREATMENT OF RECTAL DISEASES 

and extends through the back and down the thighs 
and seems to be more of a general pelvic cellulitis. 
There may be great constitutional disturbance with 
rigors, fever, and disturbance of the functions of the 
bladder. These abscesses are hard to diagnose and 
often mistaken for inflammations of the ovaries or 
broad ligaments. The disease is more chronic than the 
other forms and may last for weeks or even months 
before its true nature is ascertained and at times rup- 
ture may take place into the peritoneum or possibly in- 
to the bladder or vagina. Examination on the outside 
only reveals a tenderness on deep pressure but the 
finger in the rectum can generally outline a thick in- 
durated mass high in the bowel wall. In men the uri- 
nary symptoms are often so much more prominent than 
the rectal that the patient is treated by the passage 
of sounds and washing out the bladder and no atten- 
tion is paid to the rectum. Examination of the blood 
to see whether or not there is an increase of white 
corpuscles is always indicated if a diagnosis cannot 
be arrived at in other ways. Speculums and procto- 
scopes should not be used as they are liable to rupture 
the abscess inside the bowel. 

Treatment. An abscess in this region should be 
treated as it would in any other place, viz., by free 
incision and drainage. Most patients do not consult 
a physician until the abscess has ruptured or is about 
to do so and there is little opportunity to treat the 
case properly as might have been done earlier. If the 
pus has escaped before the patient has already consult- 
ed a doctor he will probably not do so at all as the 
tension has been relieved and he feels so much better 
that it does not seem necessary. When seen early, if 
there is the least suspicion of pus, a free opening 
should be made and the necrosed tissue scraped out ; 



ABSCESS 



101 



in this way healing will take place without the forma- 
tion of a fistula. Xo possible harm can be done by the 
incision even if no pus is found and it may avoid serious 
suppuration. Should the patient absolutely refuse to 
allow this, he should be put to bed, a cathartic given 
and after it has acted, the bowels bound up with cam- 
phor and opium and the colon well cleansed with hot 




Fig. 28. 



Showing T shaped opening in rectal abscess. 
(Goodsall and Miles.) 



water, after which ice should be applied on the out- 
side. In this way, the formation of pus may be avoid- 



102 TREATMENT OF RECTAL DISEASES 

ed. If it is seen that suppuration is taking place in 
spite of this treatment there is nothing to do but ap- 
ply hot compresses and wait for nature to bring the 
pus to the surface. I would advise that the physician 
insist on an early operation, as in this way many fistu- 
las will be avoided. 

If the abscess is in the pelvi-rectal space the in- 
cision should be very free and the pus allowed to es- 
cape, after which it should be irrigated and packed 
firmly to avoid hemorrhage. If the wound has a ten- 
dency to close at the external opening, it should be 
incised at right angles to the first incision. 

In the sub-mucous abscess, if it has not already 
broken inside the bowel, an opening should be made on 
the outside and the pus allowed to escape. 

The after treatment consists in daily irrigation with 
weak bi-chloride, about 1-4000, and keeping the parts 
open externally to get good drainage. The wound 
should not be packed very tight after the first dressing 
is applied. 



CHAPTER VI. 

FISTULA. 

A fistula is a pathological communication be- 
tween some cavity of the body and the outside. The 
ancients thought there was a pipe or reed leading 
from the inside to the outside because of the fact that, 
in rectal fistula, there was an escape of gas. Some 
fistulae, while they may be complete, are so tortuous 
that it is impossible for even gas to work to the out- 
side. 

Fistula are divided into complete and incomplete, 
and these are subdivided into blind internal or those 
having no opening on the outside, and blind external 
or those having no opening on the inside. The com- 
plete have both an internal and an external opening. 

In addition to the above, we have the complex or 
so called horse shoe fistula where there are two or 
more external openings, but this is only a form of 
the complete variety. 

Etiology. Nearly all fistulas originate from an 
abscess and as these have been considered in a previous 
chapter, but little more will be said on the subject. 
The only exceptions are fistulas caused by punctured 
wounds. 

The question is often asked why fistulas do not 
heal more readily in this region when the external 
opening is in condition to allow good drainage. Pro- 
bably the most plausable reason is because of constant 
reinfection and the passage through the sinus of the 
different pus producing germs of the bowel. This 

103 



104 TREATMENT OF RECTAL DISEASES 

does not seem to account for the non closure of the 
external incomplete variety. I am convinced that but 
very few are actually without an internal opening 
into the bowel. Many times we cannot find this 
opening even though it actually exists. Aside from 
this, however, the opening on the outside is generally 
close enough to the anus to allow reinfection from 
this source. These fistulous tracks are seldom straight 
and while they seem to be well drained in fact they 
are not and may be in direct communication with an 
old abscess cavity. In addition, the constant move- 
ment of the parts, both in walking and the evacuation 
of the bowels, prevents healing. 

Location. A fistula may occur in any part 
of the pelvis where the formation of an ab- 
scess is possible. The most common place for the 
external opening is between the two sphincter muscles, 
but it may occur at any place around the anus or the 
perineum. It is not uncommon for more than one 
fistula to be present with no apparent connection. As 
spoken of under the head of abscess, when pus bur- 
rows from an ischo-rectal fossa behind the rectum 
to the other fossa it usually breaks through the pos- 
terior surface of the bowel and later breaks on the 
outside between the tuberosities of the ischium and 
the anus and a horse shoe fistula is the result. 

Symptoms and Diagnosis. The first thing that 
caused the patient to seek medical aid was the abscess 
that preceded the fistula, and this has been fully con- 
sidered. After the fistula has become established it will 
make itself manifest by the discharge of pus either on 
the surface or into the bowel according to where the 
opening is. Taking them in separate order we will 
discuss the symptoms of each variety. 



FISTULA 



105 



Incomplete External Fistula. This does not open 
into the bowel, or at least no opening can be found. 
There is generally a discharge that seems to be mostly 
serum with but little pus in it. Often the discharge 
is so small that it is not necessary to wear a cloth to 
catch it and may even cease entirely and the external 
opening close, but it soon reopens. While it is closed 
there is a feeling of weight and pain which is relieved 
when it breaks. The worst feature of this form of the 
disease is its effect on the skin as this, by being bathed 



1 




A- 






\ 




B- 




Ikni 


\ 




C 




m 




\ 






A 


~- — El 


\\ 






f 


^^— F 


\ M— 










) L-J 






&i~L 


>^° 


"" 


KJ 




7i > 


C 



Fig. 29. Elind external fistula diagrammatically represent- 
ed. A, mucous membrane; B, submucous tissue; 
C, circular muscular fibres; D, longitudinal muscular 
fibres; E, pelvi-rectal space; F, levator ani; G, ischo- 
rectal fossa; H, integument; I, tendinous insertion of 
the longitudinal muscular fibres; J, deep portion of 
external sphincter; K, superficial portion of the ex- 
ternal sphincter; L, interval between internal and ex- 
ternal sphincter; M, the internal sphincter; X, main 
track of fistula. — (Gcodcall and Miles.) 



10G 



TREATMENT OF RECTAL DISEASES 



in the serum and pus, soon becomes thickened and a 
pruritus may be established that will be hard to get 
rid of after the fistula is cured. 




Fig. 30. Blind internal fistula diagrammatically represent- 
ed. A, mucous membrane; B, submucous tissue; C, 
circular muscular fibres; D, longitudinal muscular 
fibres; E, pelvi-rectal space; F, levator ani; G, ischo- 
rectal fossa; H, integument; I, tendinous insertion of 
the longitudinal muscular fibres; J, deep portion of 
the external sphincter; K, superficial portion of ex- 
ternal sphincter; L, interval between internal and ex- 
ternal sphincters; M, internal sphincter; X, the ab- 
scess and fistula. — (Goodsall and Miles.) 

Incomplete Internal Fistula. This is the most dif- 
ficult form of the disease to diagnose. It is generally 
caused by a submucous abscess and the main thing 
complained of is pain at stool together with a discharge 
of pus. The patient will generally give a history of 
having had the symptoms usually accompanying the 



FISTULA 107 

formation of pus as outlined under the heading of 
submucous abscess with a sudden discharge of pus 
and blood which relieved him greatly but the pus con- 
tinues to discharge more or less at intervals although 
there is now but little pain. The disease may entirely 
disappear at intervals but is sure to recur. The best 
way to make a diagnosis is with the fenestrated slide 
speculum. The internal opening can usually be felt 
with the finger but not in all cases. If this can be 
first located the speculum should be introduced and 
the slide withdrawn after having been placed over the 
supposed opening. By making pressure about the 
parts with the finger pus may be seen bubbling up 
into the bowel. By the use of a bent probe the extent 
of the track may be ascertained. Treatment should 
be carried out at the time the diagnosis is made as 
it can be done painlessly. This will be described later. 
Complete Fistula. There is but little difficulty as 
a rule in making a diagnosis of a Complete Fistula. 
The patient will often arrive at a diagnosis before he 
consults a physician. There will be a history of a previ- 
ous abscess which has broken and discharged pus and 
may have refilled and broken several times until the dis- 
charge became constant. There is an escape of gas and 
fecal matter through the external opening and this with 
the pus and broken down tissue makes it very hard 
to keep the parts clean and a disagreeable odor is al- 
ways present which is very unpleasant to other people. 
The discharge is usually greater than in either of the 
other varieties ; its amount will show the quantity of 
tissue involved and the extent of burrowing that has 
taken place, as a short straight track will not discharge 
as much as a long one with many off-shoots or branch- 
es. The diagnosis is easily made as a rule, by introduc- 
ing a probe into the external opening and feeling in 



108 



TREATMENT OF RECTAL DISEASES 



the rectum with the finger for the other end. Some- 
times the probe cannot be made to pass through the 
internal opening although one is known to be present. 
This is because the opening through the mucous mem- 
brane is higher than that through the other tissues 
owing to the fact that the original abscess broke 
through the mucous membrane at its highest point 
and later burrowed toward the sphincter and finally 
opened in the ischo-rectal fossa. If the track is very 
tortuous, as is often the case, it may be impossible to 




Fig. 31. A complete fistula diagrammatically represented. 

A, mucous membrane; B, submucous tissue; C, cir- 
cular muscular fibres; D, longitudinal muscular fibres; 
E, pelvi-rectal space; F, levator ani; G, ischo-^ectal 
fossa; H, integument; I, tendinous insertion of longi- 
tudinal muscular fibres; J, deep portion of external 
sphincter; K, superficial portion of the external sphinc- 
ter; L, interval between the internal and external 
sphincter; X, main track of fistula. — (Goodsall and 
Miles.) ' 



FISTULA 



109 



pass a probe through it. This is not important, how- 
ever, as the diagnosis may be made in other ways. 
By palpation the course of the sinus may often be out- 
lined running under the mucous membrane or skin. 
The injection of some colored fluid as milk or methy- 
lene blue will often reveal the internal opening. Some 



7 / ■' </ 
• / / / 




\ ^ ^^ 


"V^ —— 




• — _ ■' J\ 




s^j L y — - - - 



Fig. 



32. Fistula, a. Complete, b. External incomplete, 
c. Internal incomplete. 



authors lay great stress on finding this opening but 
I think its importance over estimated, as. if the treat- 
ment is by the knife an opening can be forced through 
and if the mucous membrane is examined and divided 
as high as it is undermined the result will be perfect. 

Treatment. The incomplete external is best treated 
by thoroughly dilating the external opening by freely 
incising it and scraping out all broken down tissue and 
then cauterizing it with pure carbolic acid or silver nit- 
rate. In fact it is really converted into an open wound 
and allowed to heal by granulation. Some authors 
claim that there are no fistulas with an external open- 
ing but what has an internal one and that in case it 



110 TREATMENT OF RECTAL DISEASES 

cannot be found one should be made. I think, how- 
ever, that there are many incomplete external tracks 
that do not go near the mucous membrane of the 
bowel and to force an opening through all the inter- 
vening tissue would be foolish. 

Internal Incomplete. In case the internal opening 
is large enough to be felt with the finger, it should 
have a hooked probe inserted into it and drawn down 
until the point is seen to bulge the skin external to 
the sphincter muscle. At this place a free crucial in- 
cision is made, converting it into a complete fistula. 
It should now be well cleaned from pus and blood and 
injected with the silver solution, as already directed, 
being careful to keep the external opening dilated for 
drainage. This will almost invariably cure these cases, 
and will not necessitate cutting the sphincter muscle. 
In case the internal opening cannot be felt, and there 
is simply a burrowing of pus under the membrane, it 
is not necessary to make an opening through the skin ; 
pick up the undermined tissue with a hooked probe, 
and incise it freely to the bottom of the sinus. In 
some cases the formation of the abscess begins above 
the place where the opening is located, having bur- 
rowed some distance before it breaks through. Should 
this occur, introduce a grooved director into the sinus 
and push it to the top of the undermined tissue. It 
is then forced through so that a 'bridge is left over 
the director that should be divided. It is well to be 
on one's guard in cutting the membrane high in the 
bowel, as a branch of the superior hemorrhoidal artery 
might be severed, or even the main artery if the in- 
cision is carried too high. It should not be forgotten 
that this artery descends along the posterior aspect 
of the rectum until within four inches of the external 
sphincter, or a full finder's length, and then divides 



FISTULA 111 

into two branches that pass around the sides of the 
bowel, where they separate into many small ones. It 
is almost never necessary to go high enough to cut 
the main artery. Should it be feared, however, that 
this vessel or a branch might be included in the cut, 
make the incision between two tightly tied ligatures, 
or better still, with the thermo-cautery. 

Complete Fistula. The treatment of complete fistu- 
la may be by one of the following methods : 

1. Incision. 

2. Injection of caustics. 

3. Elastic ligature. 

4. Palliative. 

Taking them in the reverse order given above I 
will discuss each separately. 

Palliative Treatment. At first thought there seems 
to be but little that can be done in the way of treatment 
except to cure the fistula, and further it might be said 
that there is no fistula but what ought to be cured. 
There are some patients far advanced with pulmonary 
or other chronic disease upen whom operation is not 
indicated and they should be made as comfortable as 
possible. The warm sitz bath both morning and even- 
ing, pressing the track of the fistula, while in the bath, 
to remove as much pus as possible. A cloth wrung 1 
out of hot boracic acid water may be applied for an 
hour or two at a time after the bath and sterile gauze 
worn during the day. The bowels should move just 
before one of the baths is taken and a pint or more of 
boracic acid solution injected to wash out any remain- 
ing fecal matter and cleanse the internal opening. The 
bowels should not be allowed to get too loose as fluid 



112 TREATMENT OF RECTAL DISEASES 

fecal matter will find its way into the fistulous track 
and aggravate the trouble. If the bowel contents are 
inclined to be hard and dry an ounce of oil injected 
previous to a movement will act favorably and be bet- 
ter than cathartics. 

Elastic Ligature. This treatment seems to mc the 
poorest that could be adopted, but as it has been used 
for many years and still finds its way into text books, 
I will describe it briefly. 

The only thing in its favor is that it requires no 
cutting and the patient as a rule can go about his 
regular work to a certain extent. If there is any bur- 
rowing except the one straight track the method is 
likely to be a failure as these will not be included in 
the grasp of the ligature and pus pockets will form 
that will eventually work their way to the surface and 
cause new tracks. A small, round, soft rubber liga- 
ture is passed through the track by being threaded 
through the eye of a probe that has previously been 
passed and then drawn back carrying the ligature 
with it. As it is difficult to tie an elastic ligature, 
both ends are threaded through a perforated shot 
which is clamped upon them after they have been put 
upon the stretch. After the tissues have cut through 
so the ligature is loose it should again be drawn tight 
and another shot with a slit cut in it clamped on and 
the first one cut off. This is repeated until the liga- 
ture has cut its way out. This method in the majority 
of cases is exceedingly painful and many patients are 
confined to bed for a week or more. The whole area 
involved is a pus cavity that cannot be kept clean and 
many times it proves a failure. 

Injection of Caustics. Prepare the patient by the 
use of cathartic medicines, enemata, and restricted diet 
so that the colon will be as nearly empty as possible. 



FISTULA 



113 



Syringe the fistulous track with a solution of peroxide 
of hydrogen and follow with plain water. After this 
is done anaesthetize the track with a ten per cent solu- 
tion of cocaine. Now fill a good-sized rubber or glass 
syringe with a saturated solution of silver nitrate. 
Put a rubber finger cot on the index finger and place 
it firmly over the internal opening of the fistula if it 
can be found. It can usually be easily located by care- 
ful search with the finger in the bowel. Put cosmoline 




Fig. 33. Diagrammatic representation of a submucous blind 
internal fistula resulting from a fissure. A, mucous 
membrane; B. submucous tissue; C, circular muscular 
fibres; D, longitudinal muscular fibres; E, pelvi-rectal 
space; F, levator ani; G, ischo-rectal fossa; H, integu- 
ment; I, tendinous insertion of longitudinal muscular 
fibres; J, deep portion of external sphincter; K, super- 
ficial portion of external sphincter; L, interval be- 
tween internal and external sphincter; M, internal 
sphincter; X, main track of fistula. — (Goodsall and 
Miles. ^ 



114 TREATMENT OF RECTAL DISEASES 

on the skin to prevent it from being burned by the 
fluid that runs out. Introduce the syringe point firmly 
into the external opening, completely closing it, and 
with the finger covering the internal opening, force 
the intervening cavity full of the silver solution, hold- 
ing it there for a short time. ' This will not only fill, 
to its fullest extent, the main track, but also any 
branches that may be present. Remove the syringe, 
and with the finger, massage the fistula thoroughly 
to bring the medicine into contact with all parts. In 
case the internal opening cannot be located, force the 
solution in just the same, as, should it enter the bowel, 
no harm will be done. In some cases, especially if the 
internal opening cannot be found, it is better to use a 
hard rubber uterine syringe with a long nozzle with 
one or two openings that force the solution out at an 
angle of about forty-five degrees instead of from the 
point ; this will obviate, to a large extent, its being 
forced into the bowel. This is much better than the 
small silver canula that is so often used, as the latter 
is apt to be forced into healthy tissue, where no track 
exists, while with the former this could hardly occur. 
As a matter of precaution, an ounce of sweet oil should 
be forced into the bowel to prevent any possible dam- 
age to the mucous membrane that might result from the 
silver solution. Nothing should be put into the fistula 
after the silver solution has been injected. Unless the 
external opening is quite large, a crucial incision should 
be made to secure good drainage. The entire lining 
of the fistula will slough away in five or six days, and 
healthy granulations spring up to take its place. The 
external opening must be kept well dilated to allow 
drainage, and a moist corrosive sublimate dressing ap- 
plied for the first few days. If after two or three 
weeks the fistula is still present, the operation should 



FISTULA 115 

be repeated. Often the first treatment will nearly 
close the sinus, and the second one is needed to com- 
plete the cure. 

Incision. By this is meant cutting the intervening 
tissue between the sinus and the skin and searching 
out and dividing any branches that may exist. There 
are several different procedures that may be included 
under the name of incision, such as dissecting out the 
sinus intact and closing the wound with the hope of 
getting primary union, closing the internal opening 
and cutting all tracks outside without cutting the 
sphincters, etc., but I will not describe these as the 
physician who does but little of this work would 
scarcely make use of them. 

Preparation of the Patient. As careful aseptic 
measures should be carried out in these cases as though 
they were not already infected. It is of course impos- 
sible to get the parts in an aseptic condition but this 
is no reason why it should not be as near in this con- 
dition as can be. If the caustic treatment has been 
used and proven a failure it has only put the parts in 
better condition and done no harm. About the same 
preliminary treatment should be carried out as describ- 
ed in the ligature operation for hemorrhoids. In addi- 
tion to this the parts should be shaved and scrubbed 
with green soap and a moist bi-chloride dressing ap- 
plied and left on over night. I think it well to give the 
intestinal antiseptics and believe that beta-napthol 
comes nearer rendering the colon sterile than anything 
else. 

If there is not too much cutting to be done the 
operation may be carried on under cocaine anaesthesia 
but if the tracks are deep and the openings numerous, 
chloroform or ether should be used. Having placed the 
patient on the table in the lithotomy position, if general 



116 TREATMENT OF RECTAL DISEASES 

anaesthesia is made use of the sphincters are thor- 
oughly divulsed. If cocaine is used they are stretched 
as much as the patient can bear easily. A grooved 
director is now introduced into the external opening 
and allowed to find its way through the sinus into the 
bowel. If this is accomplished the finger is hooked 
over the upper end and it is pulled to the outside and 
a sharp bistoury run along the groove cutting all the 
tissue upon it. If the muscle is included in the tissue 
cut, it should be divided square across and not diagon- 
ally. Search should now be made for any off-shoots 
from the main track and if any are found they should 
be divided. In old cases where there is much hard 
cartilagenous tissue, the so-called back cut should be 
made, that is, to draw the sharp edge of the knife 
through the back wall of every sinus found. It is well 
now to trim all over-lapping edges as they may inter- 
fere with the healing process. In case the director 
cannot be carried directly through the track because it 
is too tortuous it should be carried in as far as it 




Fig. 34. Grooved director for operating on fistula. 

will go easily and the remainder of the way may be 
found by dissection without difficulty. This is really 
the best way in any case as the tissues are not distorted 
by being forced out of their natural position. After 
all tracks have been divided, all overlapping edges 
trimmed and all hemorrhage of importance stopped, 
the wounds are tightly packed with sterile gauze, a 
large pad put on and held by a T bandage and the 
patient placed in bed. 




FISTULA 117 

Horse Shoe Fistula. As already stated this form 
of the disease is due to pus burrowing from one ischio- 
rectal fossa behind the rectum to the fossa on the 
opposite side. The internal opening is nearly always 
in the posterior wall of the bowel. The incision should 
be made V shaped, cutting from the external opening 
on each side to the posterior commissure behind and 
then cutting from there to the internal opening. This 



Fig. 35. Horseshoe fistula. Lines of incision in operating. 



only necessitates cutting the sphincter muscle in one 
place. It matters not how many openings there may 
be on the outside, they can nearly always be traced to 
one opening through the bowel wall. 

After Treatment. A hypodermic of morphine 
should be given as soon as the patient is put in bed, the 
amount being regulated by the extent of the cutting. 
A pill of camphor and opium had best be given about 
twice daily for two days and the third night a couple 
of C. C. pills to be followed in the morning by liberal 
doses of salts. Twenty-four hours after the operation 
the external dressings should be removed and fresh 
ones applied but the packing should be left for at least 
forty-eight hours. When it is thought best, remove 
it by running over it hot bi-chloride solution 1-4000 by 
which means it may be drawn out quite easily. The 
new dressing should be applied loosely and not packed 
in as the first was ; its only object being to keep the 
external edges apart so healing will take' place from 
the bottom. The wound should be irrigated once daily 



118 



TREATMENT OF RECTAL DISEASES 



with sterile water, bi-chloride, or carbolic solutions. 
If the granulations become sluggish they should be 
brushed with a 20% solution of silver nitrate or the 
wound packed with guaze wet with equal parts of bal- 
sam of peru and castor oil. 




Fig. 3G. Complete fistula, showing how pus may burrow 
beneath the mucous membrane both below and above 
the opening into the bowel. 



Complications. Hemorrhage must be guarded 
against; any vessels that spurt should be grasped with 
artery forceps and tied. The packing should be put 
in very tightly and a good deal of pressure made on 
the pad with the bandage. After the reaction from the 
chloroform has taken place small vessels often relax 
and bleed freely. The dressings should be examined 
occasionally for several hours to see that bleeding is 
not going on. If it is, the dressings should be removed 
and the bleeding point searched for and tied. If too 
high in the bowel to tie it may be grasped with forceps 
which can be left on for a few hours and the dressing 
reapplied around them. Another complication is an 
action of the bowels too scon after the oneration. This 



FISTULA 119 

is due to the fact that proper preparation was not car- 
ried out before the operation. If it occurs, the bowel 
should be at once irrigated with hot boracic acid solu- 
tion and clean gauze packed in the wound if the first 
has come away or is soiled. Retention of urine often 
occurs and is due to the reflex action on the genito-uri- 
nary system. The same precaution should be taken 
as directed for hemorrhoids. In some cases the dis- 
charge will persist after it has apparently had time to 
heal. This is because some sinus has been overlooked 
and not divided. Incontinence of feces is the one 
complication that frightens the physician and often 
the patient from receiving the benefit of an operation. 
It is not as likely to occur as is generally believed as 
the external sphincter is seldom cut. If cut square 
across the fibres, the muscle will generally heal and be 
in as good condition as formerly. In my own practice 
I have never known of a case of incontinence of any 
importance but have had one or two where the cutting 
was very extensive that were slightly bothered when 
the feces were liquid, but not enough to require the 
wearing of a pad. 



CHAPTER VII 

ULCERATION. 
IRRITABLE ULCER OR FISSURE. 

The term fissure is generally used to designate the 
condition about to be described, but the proper name 
is irritable ulcer. It is spoken of as an anal fissure 
because it is never seen above the internal sphincter. 
Being located as they are where the terminal nerve 
filaments are numerous, they are very painful. This 
and their location distinguish them from the true rec- 
tal ulcer higher in the bowel, which is not very painful, 
in fact often has no pain attending it. The diagnosis 
is as a rule not hard. By separating the folds of mu- 
cous membrane and skin, it may be seen as an angry 
looking little sore that seems to cause the patient pain 
out of all proportion to its size. When a person comes 
complaining of a severe pain of a lancinating or throb- 
bing character, coming on at or soon after stool, and 
continuing for from one-half to several hours, and lo- 
cated at the anal margin, from which it seems to ex- 
tend through the back and pelvis, it is almost sure that 
he has a fissure or irritable ulcer. I know of no disease 
in which the patient can be given such prompt relief 
as this, and in no other, unless it be pruritus, is he so 
grateful. I have seen strong men cry like babies be- 
cause of pain due to an insignificant looking sore that 
seemed to be incapable of causing so much suffering. 

This disease is sometimes caused by polypoid 
growths, piles, internal incomplete fistula, or syphilis, 
and these should be searched for in all cases. 

120 



ULCERATION 



121 



TREATMENT. 

There are two plans of treatment that may be 
adopted. The first, or so-called palliative method, may 
be tried if thought best, and in case of failure, the se- 
cond, or that of incision, will invariably effect a cure. 
If the palliative method is to be used, have the patient 
keep the bowels quite soft, being careful to not cause 
diarrhoea, and restrict his diet largely to fluids. Cau- 
tion him to keep the parts clean by frequent bathing 
with cool water. Once every two or three days for 




Fig. 37. Typical irritable ulcer or fissure. 



a while brush the ulcer with a twenty per cent solution 
of silver nitrate. The advice to use the solid stick is, 
in my opinion, bad, as it is not the intention to cauter- 
ize the ulcer, but to coat it over with a solution of 
albuminate of silver. If the parts are inclined to be 
dry and crack easily, the patient should be provided 
with some heavy ointment. One composed of the car- 
bonate of lead I dr., iodoform I dr., beef suet 4 dr., is 
the best. On the other hand, if too moist, a dry powder 



122 TREATMENT OF RECTAL DISEASES 

should be used. The following is excellent: Camphor 
2 dr., carbolic acid 15 gtt., crete precip (English) 2 oz., 
zinc oxid pulv. 2 dr., perfume q. s. Reduce the cam- 
phor with alcohol and mix the other ingredients thor- 
oughly and sift through bolting cloth of one hundred 
meshes to the inch. This, by the way, is a most valu- 
able powder for chafing anywhere, and I have used it 
with great satisfaction as a toilet powder on babies in 
hot weather. 

Agnew of San Francisco speaks very highly of 
Salicylic Acid but I have not had sufficient experience 
with it to form an opinion as to its merits. The follow- 
ing formula is the one used by him. 

Acid salicylic .gr. 15-30 

Morph. Sulph gr. 1-2 

Ungt. bellad oz. 1-2 

M. Sig. Apply twice daily. 

The old formula recommended by Cripps is very 
good to relieve the pain immediately following an 
action of the bowels. 

Ext. Conii dr. 2. 

Olei Ricini dr. 3. 

Ungt. Lanoline q. s. ad oz. 2. 

Mix. 

Since the introduction of orthoform, I have found 
nothing else necessary to relieve the pain. It has the 
peculiar power of relieving pain for several hours when 
applied to broken surfaces where nerve ends are ex- 
posed. If put on an unbroken surface it is not so valu- 
able. The best way to use it is the application of the 
dry powder to the fissure but it may be put into an 



ULCERATION 123 

ointment and in this way made more convenient for the 
patient. The following is a convenient form : 

Orthoform gr. 15 

Ext. belladonna gr. 1 

Ungt. lanoline q. s. ft. ungt. 
M. 

This may be used through a hard rubber ointment 
pipe as shown on page 129 or simply applied with the 
finger. Should the pain extend well up into the rec- 
tum where it is difficult to reach, the above formula 
may be made into a suppository by substituting oil 
throbroma for lanoline. 

In case the suppositories cannot be introduced into 
the bowel because of the pain they cause, an ounce or 
two of warm starch water to which has been added 
from twenty to thirty drops of tr. opii may be care- 
fully injected as recommended in proctitis. It is sel- 
dom necessary, however, to apply anything above the 
sphincter muscle, as the fissure is very seldom above 
that point. 

The formulas given above are mainly for the re- 
lief of pain and do not have much curative effect and 
at the same time they are being used a more stimulat- 
ing preparation should be applied. There is nothing 
that has given me greater satisfaction than ichthyol. It 
may be used pure by applying it once daily to the 
fissure or if preferred it can be made into an ointment 
or suppository. The application of pure ichthyol is 
not painful and may be used freely without cocaine 
anaesthesia. It should be applied once daily by the 
doctor and not left to the patient as he will not be 
likely to do it as it should be done. If kept up patiently 
for from one to two weeks a cure may be expected in 



124 TREATMENT OF RECTAL DISEASES 

a large proportion of cases. A few, however, will 
resist all efforts towards cure and some form of opera- 
tive procedure will be required. 

OPERATION BY INCISION. 

By this method some of the muscular fibres of the 
external sphincter are divided. It is, as a rule, not 
necessary to cut the internal sphincter, or even all of 
the external. The operation is done by injecting under 
the ulcer a few drops of a solution of cocaine, and 
then drawing a sharp knife through its floor. This 
cures, not by the inflammation established, but by al- 
lowing the muscular fibres to rest until healing has 
taken place. This is proven by the fact that a cure 
results even though the incision is made through the 
muscle at some other place than the base of the ulcer ; 
also by the fact that in cases where two ulcers exist 
a single division will cure both of them. Should the 
ulcer extend too high to allow the upper end to be 
reached easily, a small speculum may be used, being 
careful to direct the blades away from the affected 
side. After the incision has been made, place a pled- 
get of cotton dipped in corrosive sublimate solution, 
one to two thousand, in the wound, and apply a pad and 
T-bandage. While this little operation is simple and 
easily done, it is one of the most satisfactory proced- 
ures in the whole range of rectal surgery, for the fol- 
lowing reasons : It permanently cures the patient, 
there is no possible danger of injury to the sphincter, 
causing incontinence, neither is there the possibility of 
death from chloroform, as might occur where the 
sphincters are forcibly dilated. The pain is instantly 
relieved, and does not return. To be sure, there is 
some pain from the cut made, but it is trivial in com- 



ULCERATION 



12{ 



parison to that due to the fissure, and soon passes away. 
The after treatment consists in keeping the bowels 
from moving for two or three days, after which a 
mild cathartic should be given, a small dose of castor 
oil being as good as anything; when the desire for an 
evacuation is felt inject into the bowel an ounce of 
sweet oil. The patient should be kept in bed for a 
few days, and a mild boric acid dressing applied. Once 
daily a hot corrosive sublimate solution, one to three 
thousand, should be used to irrigate the parts. After 
the first week the patient may attend to his ordinary 
business, although the wound will not be entirely heal- 
ed for two or three weeks. 




Fig. 38. Dilators for gradual dilation of sphincter 



GRADUAL DILATION. 

This method may be used in some cases with little 
pain, and very fair results, especially in infants. This 
disease is found quite often in children, and a promi- 
nent New York specialist in the diseases of children, 
says that "when a child cries persistently, and if it is 
certain that it is not hungry or suffering from some 



126 TREATMENT OF RECTAL DISEASES 

digestive trouble, it is always well to examine for fis- 
sure." In such cases have the nurse oil her little finger 
and carefully insert it into the bowel, going up a little 
higher each day. In case the pain is too severe, the 
fissure may be touched with cocaine solution. Some 
soothing ointment should also be used. In adults about 
the only thing that can be expected in the way of cure 
is by the introduction of a small size dilator, and when 
it gets so it can be inserted easily a larger one may be 
used ; or the surgeon may use a small speculum and 
carefully dilate the blades all that the patient will per- 
mit. This is too painful for the average patient, and 
very few of them will submit to more than one treat- 
ment of this kind. 

DIVULSION. 

Forcible divulsion under chloroform as described 
on page 68 will cure every case and is to be preferred 
where the milder methods above mentioned fail. 

It cures by causing the muscle to be at rest from 
overdistention and paralysis thus giving the ulcer time 
to heal. 

RECTAL ULCER. 

The true rectal ulcer, or that form found above 
the internal sphincter muscle, is not seen as often by 
the general practitioner as some would have us believe. 
However, it is sometimes met, and is no doubt often 
overlooked, and the patient treated for some other 
trouble. When a patient complains of diarrhcea that 
has extended over a considerable portion of time, and 
is not controlled by ordinary treatment, it is fair to 
presume that there is an ulceration of the rectum or 
sigmoid. Should the discharge be streaked with blood 
and mixed with mucus and shreds of membrane, the 



ULCERATION 127 

diagnosis will be almost certain. Pain is not a promi- 
nent symptom, and unless the ulcer is close to the 
sphincter, may be altogether absent. The diagnosis 
is best made with the tubular speculum of such length 




Fig. 39. Cylindrical speculum for examining the higher 
parts of the rectum. 



as may be necessary. If not too high in the bowel the 
proctoscope will reveal the lesion perfectly. Should 
it not do so, the sigmoidoscope may be introduced as 
for as possible, the obturator withdrawn, and a strong 
light thrown upon the tissue exposed ; by slowly with- 
drawing the instrument every portion of the surface 
of the mucous membrane from its upper end is plainly 
exposed to view. Should an ulcer be present, it may 
be easily recognized, as it will have the general appear- 
ance of an ulcer in any other part of the body. 
The disease is usually classified as follows: 
Traumatic, Syphilitic, Dysenteric, Tubercular, 
Catarrhal, Rodent. 



128 TREATMENT OF RECTAL DISEASES 

TREATMENT. 

This will depend largely upon the character of the 
disease. Many times it is impossible to tell just what 
kind of an ulcer we have to deal with, but as the general 
characteristics of all are about the same, the treatment 
will not vary a great deal. The traumatic is probably 
the most common, and is due to an injury of some 




Fig. 40. A good sponge and cotton holder for rectal work. 

kind, as an impaction of feces, foreign substances 
lodged in the rectal pouch, or introduced from with- 
out, or from ulceration ot a strangulated pile, etc. 

It is very important that the bowels be kept loose, 
and that they be well washed out after each movement 
with warm water. Two or three times a week an 
enema of water should be used containing about forty 
drops of nitric acid to the pint. This is especially 
beneficial in the catarrhal form. Once or twice a 
week the ulcer should be exposed, and a solution of 
silver nitrate, twenty grains to the ounce, applied. In 
case the edges are indurated and shelving the whole 
surface should be curetted, and pure nitric acid applied, 
followed at once by a strong solution of soda to neu- 
tralize the acid. The patient should remain in bed 
and be put upon a liquid diet while this is being done. 

The bowels should be moved daily by injecting 
a pint of flaxseed solution, or an ounce of sweet oil. 
Of course, care should be exercised in regard to cur- 
etting or applying acid to too large a surface, as there 
will be some contraction, but in the majority of cases 
the surface involved is so small that there will be no 



ULCERATION 129 

danger. When large ulcerations exist, involving near- 
ly the whole surface of the bowel, solutions of silver 
nitrate, of from five to twenty grains to the ounce, 
should be used two or three times a week. After 
allowing this to remain in the bowel for a few min- 
utes, it should be flushed out with a weak solution of 
sodium chloride and equal parts of water and fluid 
hydrastis (not fluid extract) should be used and re- 
tained if possible. In case there are varicose veins 
about the anus, and the mucous membrane seems lax 
and inclined to prolapse, Dist. Ext. of Hamamelis 
should be used instead of the hydrastis. If the ulcer- 
ation is thought to be syphilitic, treatment for this 
disease should be given and kept up for a long time. 
If this is not done the disease will return even though 
apparently cured. In syphilitic cases the ulcer should 
be dusted frequently with dry calomel. 

In the tubercular form of the disease bat little can 
be expected from local treatment. In most of these 
cases there is a local tendency toward a breaking down 




Fig. 41. Pile pipe for applying ointment to ulcers. 

of all the surrounding tissues. This is usually first 
seen by the physician as a tubercular abscess or fistula. 
Treatment should be mainly constitutional. 

The rodent ulcer is very closely allied to epithelio- 
ma, and some authors say that it is one of its varieties. 
It may be recognized by the fact that its edges end 



130 TREATMENT OF RECTAL DISEASES 

abruptly in healthy tissue ; its surface is red and dry, 
it never entirely heals, and it is one of the most painful 
of all rectal affections. It may easily be distinguished 
from the irritable ulcer by its general appearance, 
which as a rule is confined tc mucous membrane, while 
the irritable ulcer is at the junction of the skin and 
mucous membrane, and involves both ; but more espe- 
cially by the constant pain. The treatment of rodent 
ulcer is so unsatisfactory that it is not worth while to 
attempt its cure except by surgical means under chloro- 
form. 

ULCERATION OF THE SIGMOID. 

Owing to the fact that this disease is too high to 
be easily reached from below, and too low to be easily 
found by palpation from above, it is often undiscovered. 
Diagnosis must be made mainly from subjective symp- 
toms. 

The chief symptoms of inflammation of the sig- 
moid and colon are diarrhcea and abdominal pain, but 
pain is often not prominent except in acute cases. 
Diarrhcea, however, is always present, varying in de- 
gree according to the severity of the condition, and 
whether simple inflammation or ulceration is present. 
If there is simple acute or subacute inflammation, the 
stools contain no blood, but are very frequent and 
watery ; if ulceration be present, blood and shreds of 
membrane will be present. The stools often number 
fifteen to twenty-five a day, and in many cases the 
desire to empty the bowel is constant. In addition 
to the above prominent symptoms there will be marked, 
constitutional changes', such as loss of flesh, sallownes? 
of the skin, and general weakness. Owing to the 
large amount of watery elements taken from the blood, 
there is considerable disturbance of the circulatory 



ULCERATION 131 

system, including palpitation, weak pulse, and short- 
ness of breath. The general weakness, and sometimes 
apparent lung trouble, lead the practitioner to suspect 
tuberculosis, and, although the tubercle bacilli cannot 
be found in the sputum, the bowel symptoms would 
indicate intestinal tuberculosis. Owing to this diag- 
nosis many patients have died who might have been 
saved had a true knowledge of the trouble been arrived 
at. 

It is sometimes very difficult to make a differential 
diagnosis between ulcerative colitis and tuberculosis 
of the intestine, though in the latter there are often 
well marked lung lesions, which may readily be de- 
tected. The most marked evidences of intestinal tuber- 
culosis not found in ulcerative colitis are irregular 
fever, loss of flesh, sometimes constipation, and pro- 
fuse sweating, especially at night. The main symp- 
toms, however, are so nearly identical in both diseases 
that it is often difficult to distinguish between them. 
Dr. Mathews says : "The patient drifts from bad to 
worse, and after a while is a confirmed invalid. May 
it not be for want of proper treatment? I am certain 
that many doubtful cases of diarrhoea or dysentery 
would find an explanation if the sigmoid were searched. 
Indeed, I have treated many cases and carried them to 
a full convalescence that had "gone the rounds" as 
chronic diarrhoea or dysentery. For all such patients 
I would suggest that" the flexure be explored and 
treated, and many will clear up." 

I fully concur in the above statement, and feel sure 
that several cases under my care have been cured 
that would have died had the usual treatment by in- 
ternal remedies been continued. In addition to the 
methods of diagnosis already mentioned, we can, by 
using the sigmoidoscope and electric light, arrive at an 



132 TREATMENT OF RECTAL DISEASES 

absolutely correct knowledge of the conditions present 
in most cases. 

Treatment consists mainly in giving the patient 
but little bulky food that will load the colon, and follow- 
ing about the same lines as directed for rectal ulcera- 
tion. The mild astringents as Fl. Hydrastis, Pinus 
canadensis, weak solutions of silver nitrate, etc., should 
be used daily. Once a week, if there is much blood 
discharged, a solution of silver nitrate, ten grains to 
the ounce, should be used. Hot water in large quanti- 
ties has a stimulating effect upon the mucous mem- 
brane, and should be used freely. This is done just 
preceding the injection of the medicine, and the latter 
is then injected and retained. In giving a high enema, 
the surgeon should use a Wales rectal bougie, but 
where the patient or nurse attends to this, I believe 
so stiff an instrument is dangerous in inexperienced 
hands, and might perforate the bowel. Some patients 
can force water into the colon with an ordinary syringe, 
while with others it can scarcely be made to enter 
even the descending colon. 

There is considerable skill required in giving a 
high injection. As usually given, little, if any, more 
than the rectal pouch is filled, when the desire for 
an evacuation becomes so urgent that it cannot be 
retained, and of course, does no good. The patient 
should be placed on his side or back, as preferred, 
with the hips elevated, and a long rectal tube carefully 
introduced so far as it will go easily. When an obstruc- 
tion is reached, a little water forced gently through 
the tube will usually relieve it from the folds of mem- 
brane in which it is caught, and it can then be pushed 
on until it passes the sigmoid, and the end lies in the 
descending colon. Now, if the fluid be allowed to 
flow very slowly to the upper part of the colon first, 



ULCERATION 133 

the rectal pouch will be rilled last, and of course, all 
desire for an evacuation will be prevented until the 
large bowel is nearly or quite full. By removing the 
rectal tube from the attachment to the syringe or 
irrigator, the water can be allowed to flow out and a 
fresh supply introduced, thus filling and emptying the 
entire colon, so that the medicine used has been brought 
in contact with all the diseased membrane. A tube 
with an opening in the end, made for washing out 
the stomach, is better than an 1 ordinary rectal tube, 
as the latter is too short. Any intelligent person can 
be taught to do this properly, and while it necessitates 
a great deal of work, the seriousness of the disease, 
and the results that may be expected, will fully repay 
the trouble. 

IRRIGATION OF THE COLON. 

There are certain conditions of the pelvic organs 
in which irrigation of the colon with hot sterile water 
or normal salt solution is of great benefit, not only 
to the diseased organs themselves, but to adjacent 
organs. When it is remembered that the pelvic con- 
tents are very closely related, both as to position and 
blood supply, and that their nerves are all from practi- 
cally the same source, it is easy to appreciate how the 
application of moist heat to the interior of the colon 
would be beneficial to other organs. 

The effect locally is to wash out hardened fecal 
matter, dissolve and remove tenacious mucus, broken 
down epithelium and other catarrhal products, and 
stimulate the secreting glands as well as the muscular 
wall of the bowel, thus arousing its peristaltic action. 
In addition, the kidneys are aroused to increased action, 
and as considerable water is absorbed through the 



134 TREATMENT OF RECTAL DISEASES 

blood vessels of the bowel, the amount of urine is 
increased, carrying with it much waste matter. 

The benefit to other pathologic conditions of the 
pelvic cavity is derived from the local heat in addition 
to the general effect upon the circulation and kidneys, 
and this procedure is indicated in pelvic inflammations 
of almost any character ; also in collapse, shock, dysen- 
tery, yellow fever, typhoid fever, etc. In suspected 
cases of the latter disease I have by lone-continued and 
repeated irrigations removed hardened fecal matter 
from the region of the cecum that had resisted the 
action of the most searching cathartics, and apparently 
had lain in that locality for weeks. After their removal 
the typhoid symptoms would at once clear up. In 
these cases there seems to be an accumulation of fecal 
matter which acts as a reservoir from which toxines 
are absorbed. I believe this to be true also in many 
other diseases, as cephalalgia, vertigo, indigestion, anae- 
mia, chlorosis, and to a limited extent, in many others. 
One of our best clinicians has been quoted as saying 
that in his opinion ''acute interstitial nephritis is often 
caused by the extra work thrown upon the kidneys, 
due to a constantly overloaded colon." Sir Andrew 
Clark said that his reputation was made largely by 
his success in treating chlorosis, and this consisted 
mainly in keeping the colon free from toxines, and 
the judicious use of iron. This being true, the value of 
flushing the colon with hot water is no doubt superior 
to the use of cathartics. In retention of urine, especi- 
ally if due to spasmodic action, a ten-minute irrigation 
of the colon with water as hot as can be borne, will in 
many instances, start the flow. In acute inflammatory 
conditions of either the colon, rectum or adjacent parts 
the irrigation should be done two or three times a 
day, and continued for from fifteen to thirty minutes, 



ULCERATION 135 

using a double current rectal tube ; by compressing 
the outflow tube the colon may be completely filled, 
in this way keeping from two to three pints of water 
in contact with the rectal wall all the time. If the 
water is very hot, it will not as a rule cause colicky 
pains, and if allowed to flow slowly at first, the desire 
for an evacuation, which usually occurs as soon as 
the rectal pouch is filled, will soon pass away ; a long 




Fig. 42. Double current irrigating tube. 

rectal tube is not necessary. The best position is on 
the back with the hips slightly elevated, and a fountain 
syringe with a fall of about four feet is to be preferred. 
In case there is no inflammatory condition, once or 
twice a week is often enough to use the water, and 
unless there is some well-defined reason for doing so, 
it should not be used at all. In ordinary constipation 
it should be considered as only an adjunct to other 
measures, to be discontinued as soon as possible. The 
use of this treatment in health or as a constant practice 
in constipation, is to be deprecated, as it washes away 
the natural secretions and destroys the rectal nerves 
so that a bowel movement cannot be had without this 
unnatural stimulus. 



CHAPTER VIII. 

PROLAPSE OF THE RECTUM. 

Used in its broadest sense, prolapse means a falling 
or descent of the bowel so that it protrudes outside 
the body. The disease is one that causes a great deal 
of suffering and in some of its forms is very hard 
to cure. In procidentia the bowel may not appear out- 
side of the body in its early stages but will do so if 
left untreated. 

The disease is divided into two kinds, the complete 
and incomplete. The complete is that form in which 
all the coats of the bowel, in some cases even the perit- 
oneum, are protruded, while in the incomplete only 
the mucous membrane comes out. The incomplete or 
partial form in its early stages is only an exaggerated 
protrusion of the normal mucous membrane as it turns 
outside the anus at defecation. Under certain condi- 
tions it becomes protruded farther and farther until it 
becomes pathological. 

As before stated a procidentia or intussusception is 
a doubling or invagination of the bowel within itself 
and it may or may not protrude at the anal orifice, de- 
pending entirely upon at what period of its develop- 
ment it is met with. 

Incomplete or Partial Prolapse. This occurs 
nearly always among children and generally has its 
origin in the summer diarrhces and is brought about 
by straining at stool. Anything that causes excessive 
straining such as stone in the bladder, phimosis, etc., 
may bring it about. In children the sacrum is very 
much less curved than in older people and the pres- 
sure is more nearly in a straight line than it is in adults, 
in whom it is against the curve of the sacrum. 

136 



PROLAPSE 137 

Paralysis of the nerves that supply the parts or 
any condition that takes away the natural support 
from below, as a relaxed sphincter muscle, may cause 
it. 

As a rule the prolapse comes on suddenly and the 
mother or nurse is greatly frightened ; again it may 
come on slowly and be several months in developing. 
Some authors say that it never developes suddenly but 
in this I am sure they are mistaken as I have seen 
several cases in my own practice that came without 
any previous symptoms. The first thing the mother 
recognized as being out of the normal was a mass two 
or three inches in length protruding from the anus. 

Symptoms and Diagnosis. As just stated, the first 
thing noticed is a protrusion of a mass from one to 
three inches long extending from the anus immediate- 
ly following a severe fit of straining. This will not 
return of its own accord as the sphincter muscle is 
highly irritated and is inclined to spasmodically con- 
tract. The longer it remains out the more swollen and 
congested it becomes. It cannot well be mistaken for 
anything else unless it might be hemorrhoids, but 
these come down in distinct tumors that are attached 
to one side of the bowel, while prolapse is a ring all 
around and does not come down much if any more 
in one place than another. There is one condition 
that is often seen in adults that is very confusing to 
the inexperienced. These are the cases where there 
are several large internal hemorrhoids that do not 
entirely protrude but force a ring of mucous membrane 
down in front of them. A careless examination re- 
veals nothing but the prolapsed bowel and the cause 
immediately above it is overlooked. By having the 
prolapse forced out and then asking the patient to 
strain down with considerable force they mav be seen. 



138 TREATMENT OF RECTAL DISEASES 

They may easily be felt at this time by the examining 
finger. In case the prolapse comes on slowly, it is 
accompanied by a lax sphincter which removes the sup- 
port that holds it up and as this is essentially a disease 
of childhood the mother will observe the condition 
before it becomes serious and have such measures 
adopted as will check it. The differential diagnosis 
between this and the complete form will be discussed 
under the latter. 

Complete Prolapse. This occurs most often in 
adults and is a much more serious matter than the 
partial. All the coats of the bowel protrude, even 
the peritoneum in some cases, and occasionally 
coils of small intestine. It may be distinguished from 
the partial by its thick solid feeling and also by the fact 
that the folds run around the mass while in the partial 
they are longitudinal. The disease is not likely to 
be complicated with hemorrhoids. It comes on gradu- 
ally and may be due to unusual force applied from 
above or lack of support below, or both combined. 
Chronic constipation, especially when accompanied 
with catarrh of the bowl, may cause a gradual thicken- 
ing of the walls that may, bring it about. When once 
the bowel has begun to protrude the constant irritation 
occasioned by its slipping out and in will cause 
hypertrophy of its walls that make it too large for the 
place it is supposed to occupy and for this reason 
nature is constantly trying to force it out. Polypoid 
growths of the sigmoid may drag the bowel down 
until it protrudes. 

There are three forms of complete prolapse re- 
cognized by most authors, all of which are really differ- 
ent degrees of the same condition. The first is that 
just described or where all the coats of the bowel are 
forced out, beginning at the anus. The second is 



PROLAPSE 



139 



where the beginning of the descent is slightly above the 
anus and the third is where the beginning is a long 
distance above the anus or possibly in the sigmoid or 
colon. In each of the two latter forms there is a dis- 
tinct sulcus into which the finger may be placed be- 
tween the protruding part and the sphincter muscles. 
This is not true if the third form has not appeared at 
the outside, as is sometimes the case. While these 
cases are extremely rare I will quote the description 
given by Van Bueren, as it is very plain, ist. "The 



Y - 


J, ■-. ■ '•■.'- \ 


US 


£j 


1 


1 
■ • i 



Pij 



43. 



Complete prolapse of the rectum. (Tuttie.) 



most common, in which the greased finger, passed 
carefully around the base of the tumor, recognizes 
that its external surface is absolutely continous with 
the membrane that lines the orifice of the anus without 
the existence of a sulcus. Here the bowel begins to 
slip out originally by its very lowest portion, and this 
had gradually formed the outer layer of the protrusion, 
the gut, as it is forced down from above, passing 
within it. This form of complete prolapse follows 



140 TREATMENT OF RECTAL DISEASES 

simple protrusion of the mucous membrane, or par- 
tial prolapse when the latter has been neglected. It 
results from a persistence of the causes which are 
keeping up the latter, and effecting its gradual in- 
crease by dragging upon the outer coat of the gut, 
when the submucous connective tissue will no longer 
yield. Such, a tumor always contains more or less 
peritoneum, and it is important that you should never 
lose sight of this fact. The peritoneum, you will 
remember, surrounds the rectum on all sides and ex- 
tends downward to an oblique line three inches and a 
half from the anus in front and scarce five behind. 
The peritoneal reflection at the base of a protrusion 
of this kind, is therefore always larger in front. 

2nd. Where the finger can be inserted into 
a groove alongside the base of a tumor, so as to re- 
cognize a distinct sulcus, of more or less depth,, at 
the bottom of which, if not too deep, the lining mem- 
brane of the gut may be felt as it is reflected from 
the base of the protruding tumor. In this case the 
rectum has begun to fold upon itself. In other words, 
to become invaginated, or, in the language of the day, 
'telescoped,' the upper part of the bowel always passing 
within the lower, at a point more or less distant from 
the anus, yet generally within reach of the finger. 

3rd. In this variety the finger can be inserted 
through the anus alongside the protruding tumor, but 
cannot reach any line of reflection of the mucous mem- 
brane of the rectum upon the tumor, the latter, in fact, 
may not even as yet have protruded through the anus, 
but may be felt only as a polypoid mass, occupying 
the cavity of the rectum. Here invagination has taken 
place higher up in the colon; has possibly commenced 
in the caecum or even in the lower part of the illium, 
which, sucked through the ileo-caecal valve, has been 



PROLAPSE 



141 



carried with the caecum itself up the ascending colon, 
and, the connecting attachments gradually yielding, 
the invaginated mass has been propelled along the 
whole length of the colon and finally presents itself 
in the rectum, or may possibly extrude externally. 
This almost incredible displacement of the parts has 
now been certainly recognized in so many recorded 
cases, examined after death, that it were inexcusible 
to fail to recognize it during life." 




Fig. 44. Incomplete prolapse of the rectum. — (Tuttle.) 



TREATMENT. 

Partial Prolapse. Often the first thing the physi- 
cian is called upon to do is to reduce the prolapse. If 
it has been out a long time this may be a difficult thing 
to do. The parts become dry and swollen and if the 
patient is a child it will cry and strain until it seems 
impossible to get it back. Gravity helps more than 
anything else and the child should be as nearly inver- 
ted as possible ; this will carry the contents of the ab- 



142 TREATMENT OF RECTAL DISEASES 

domen and pelvis away from the rectum and the pro- 
truded mass will usually slip back in place. Gentle 
taxis should be made upon it while this is being done, 
always remembering that the part that came out last 
should go back first. If the above measures fail, 
chloroform should be given which will relax the mus- 
cles and stop straining sufficiently to allow it to be re- 
duced easily. In most cases there will be no further 
trouble if a little care is used by the mother. The 
patient should be put in bed and kept there for some 
time and the buttocks drawn together with a broad 
strip of adhesive plaster. When it is necessary for 
the bowels to move the plaster may be cut through 
the center and later drawn together with laces. The 
child should not be allowed to sit on the commode but 
be made to use a bed pan. After the movement a 
little cold water should be injected into the bowel, 
to which has been added some alum, fluid hydrastis 
or other astringent. Of course if there is anything 
that is keeping up the irritation and straining, like 
phimosis, stone in the bladder, hemorrhoids, etc., they 
should be attended to. If these palliative measures are 
not sufficient, more radical ones should be adopted. 
Allingham recommends the application of pure nitric 
acid. Some prominent men say it should never be 
used. In my hands it has been very satisfactory when 
used on children but is not very satisfactory in adults. 
The object is to establish an inflammatory action that 
will cause the mucous coat to adhere to the tissues 
immediately beneath it. To do this the protruded mass 
is rendered insensible to pain by the application of 
cocaine and four or five lines are made with acid in 
the long axis of the protrusion. After waiting a few 
minutes a strong solution of soda is applied to neutra- 
lize the acid. The child should be put in bed and 



PROLAPSE 143 

kept slightly under opiates to relieve pain and bind 
up the bowels. The diet should be very light and no 
bowel movement allowed for four or five days. About 
the same result may be obtained by applying the cau- 
tery at a dull red heat. This is done in the same way 
as the acid only the application is made before the pro- 
lapse is forced out. Tuttle recommends an injection 
at several points around the circumference of the anus 
of from three to five drops of modified Shufords so- 
lution. After this is done a rubber drainage tube is 
inserted and the rectal ampula packed with gauze to 
bold the gut in position. This will allow the escape 
of gas and the bowels should be bound up for from 
seven to ten days. He advises that "a firm compress 
be put over the anus and the patient be kept more or 
less under the influence of opiates." "If carefully 
performed with proper antiseptic precautions, there 
is no danger of suppuration or sloughing in this meth- 
od, and the percentage of cures is fully equal to that 
by the cauterizing methods mentioned above." 

The modified Shufords solution referred to is pre- 
pared as follows and is recommended by the same 
author for the injection of hemorrhoids. 

Acid carbolic (Calverts) dr. 2. 

Acid salicylic dr. y 2 . 

Sodii bi-borate * .dr. 1. 

Glycerine (sterile) q. s. ad oz. 1. 

M. 

Treatment of Complete Prolapse. This depends 
upon the conditions present. There are three main 
indications viz : — to remove any exciting cause, as 
hemorrhoids, tumors, etc., to hold the bowel up from 
above and to improve the support below. In addition 
much good may be accomplished by proper constitu- 



144 TREATMENT OF RECTAL DISEASES 

tional treatment. Many of these cases are greatly 
debilitated from long illness or other causes and if 
the prolapse can be held in place until the general 
health is improved it will remain there. The methods 






s 




Fig. 45. Complete prolapse originating above the internal 
sphincter. — (Tuttle.) 

described for partial prolapse will not be applicable 
in 1 the complete form. If the mass is too large to 
remain in its place when reduced, and constantly acts 
as a foreign body, an operation may be done with the 
clamp and cautery the same as recommended for 
hemorrhoids, only instead of removing tumors three 
or four sections of the bowel are clamped and cauter- 
ized, each being removed in the long axis of the bowel. 
The prolapse is then reduced and kept confined for 
several days. This sets up an inflammatory action that 
unites the whole intestinal surface to the surrounding 
parts and at the same time reduces the size of the rec- 
tum so that it ceases to be too large and no longer acts 



PROLAPSE 



145 



as a foreign body. If in addition to the operation just 
described, the abdomen is opened and the bowel drawn 
tip until it will come no further and then fastened 
in the abdominal wound the cure is likely to be per- 
fect. 

There are several most excellent operations for 
the cure of complete prolapse but as they come under 
the head of major surgery, the reader is referred to 
the larger textbooks for a description of the technique. 




Fig. 46. Complete prolapse which begins high in the 
rectum or sigmoid and does not appear outside. 
— (Tuttle.) 



CHAPTER IX. 

NON-MALIGNANT GROWTHS. 

It is a well known fact that in all mucous cavities 
of the body there may be found new growths of a 
benign nature. These are especially liable to affect 
the lower end of the large intestine because of its 
more exposed position and greater chance of being 
injured. These growths may be found in all parts 
of the intestinal canal but are much more frequent in 
the rectum. According to Leichenstern they occur in 
about the following relative frequency in the intestinal 
canal : — Duodenum, 2 ; ilium, 30 ; ilioceacal valve, 2 ; 
ceacum, 4; colon, 10; and rectum, 75. 

The general practitioner is likely to designate all 
of these growths as hemorrhoidal and even good sur- 
geons often fail to diagnose them properly. When 
small they cause but few symptoms and unless they 
protrude may be entirely overlooked. Bodenhamer 
says, "The writer in a private practice of fifty-nine 
years, has treated ninety cases of rectal polypi, so called, 
in persons aged from three to seventy-five years ; 
fifteen were in children under five years old, forty-five 
were adult females, and thirty were males." Some 
men prominent in the profession say that they never 
saw a case, but no doubt, like many other diseases that 
were unknown in the past and are now considered new, 
better methods of diagnosis and more perfect atten- 
tion to the technique of examination enable us to 
recognize these cases where we would not have done so 
in the past. 

146 



NON-MALIGNANT GROWTHS 147 

These new growths or neoplasms are generally 
called polypi, but the latter term includes all tumors 
that are attached by a pedicle that is smaller than the 
tumor itself, so any growth may be a polypus but any 
polypus is not necessarily a special variety of tumor. 
Many tumors are attached by a broad flat base and yet 
they go by the name of neoplasm or polypus and 
as these terms have in the past been regarded as 
synonymous they will be so considered here. 

As before stated, these tumors may be found in 
any part of the intestinal canal but are more frequent 
in the rectum and the most common point is the lower 
three inches of this cavity. They may occur singly 
or there may be two or more ; in rare instances the 
whole mucous membrane may be covered with small 
granular masses not larger than a mustard seed. They 
are generally pyriform in shape and are attached by 
a slender pedicle, but they may be round and have 
the appearance of earth worms, some of them measur- 
ing two or three inches in length. In size these 
growths do not as a rule get larger than a hen's egg 
but there have been cases reported where the tumors 
were as large as a medium sized orange. 

The consistency and texture of these growths 
varies but they are usually soft and pliable, often 
feeling like mucous membrane. In appearance they 
are smooth in the early stages but may become tabu- 
lated and roughened by the irritation of hard fecal 
matter. The constant tension to which they are sub- 
ject during a bowel movement tends to lengthen the 
pedicle and in some cases they are actually forced out 
and the pedicle torn from its attachment, thus effect- 
ing a cure. They may be complicated with other 
diseases and in most of the cases that have come under 
my observation there have been hemorrhoids in addi- 



148 TREATMENT OF RECTAL DISEASES 

tion to the other tumors. The fibroid tumor is said 
to be the cause of fissures or irritable ulcers because 
of the effort on the part of nature to force them out, 
thus lacerating the mucous membrane. 

Symptoms and Diagnosis. In the early stages there 
are no symptoms, but when the tumor becomes well 
enough developed to protrude, it at once makes itself 
manifest and is usually considered a hemorrhoid. If 
located in the upper part of the rectal cavity, there may 
be a discharge of mucous and blood mixed, thus making 
it difficult to distinguish between the malignant and 
non-malignant form of the growth. As the treatment 
would be the same in either case it does not matter 
especially as the microscope will settle the question 
after removal. There is not much pain unless the 
growth is quite large when there may be a feeling 
of weight in the pelvis with dull aching pains in the 
back and down the thighs. There will also be a good 
deal of tenesmus and a feeling that the bowel is not 
entirely emptied. Hemorrhage from t:he bowel in 
children is very often due to one of these growths 
and if not diagnosed early, there may often be seen 
at the anal orifice a small bright red strawberry-like 
tumor that will appear at each movement of the 
bowels and be retracted out of sight in the mean time. 
In all doubtful cases the finger, speculum or procto- 
cope will generally clear up the diagnosis. 

Classification. These growths are usually classi- 
fied as follows. A brief description of each will be 
given. 

Adenoma. Lipoma. 

Fibroma. Cystoma. 

Papilloma. Enchondroma. 

Teratoma. Angioma. 



NON-MALIGNANT GROWTHS 



149 



Adenoma. This is simply an exaggeration of the 
minute glands, follicles, or crypts of Lieberkuhn. They 
are generally found in young persons and may be 
single or multiple, never growing to be very large. 
They are attached by a short thick pedicle. They are 
very vascular which gives them a bright red color. 
As this growth is made up of an accumulation of the 




Fig. 47. Vertical section of simple adenoid. — (Kelsey.) 

normal follicles of the bowel, it is at first simply a 
raised or thickened place in the bowel wall. As it 
continues to grow, the movement of the fecal mass 
against it constantly pushing it down so stretches the 
walls of the tumor that a pedicle is formed, in some 
cases long enough to allow the tumor to be forced 
outside. 



150 



TREATMENT OF RECTAL DISEASES 



Fibroma, This is the tumor found most often in 
the uterus. It is composed of fibrous tissue but may 
have glandular and muscular elements. It is most 
often found in adults. It originates in the submucous 




Fig. 48. Multiple adenoma of rectum. — (Tuttle.) 



connective tissue, is covered with smooth mucous mem- 
brane, generally has a distinct pedicle, and often at- 
tains a large size. In some cases the tumor remains 
in the bowel wall and has no pedicle. Tumors of 



NON-MALIGNANT GROWTHS 151 

this kind have been reported that were as large as 
a fetal head. 

Papilloma. This is an outgrowth or enlargement of 
the papilla at the muco-cutaneous border of the rectum. 
They may be combined with the adenoma in which 
case we have the so-called adeno-papilloma. This 
growth appears as long slender processes and is usu- 
ally seated on a wide base. 

Teratoma. This is one of the most infrequent of 
all these growths. It is a congenital tumor and is 
composed of seme of the elementary cells of the body. 
Such tumors are not rare in other parts of the body 
and are most often found in connection with the 
ovaries. In the rectum, however, they are quite un- 
common. These growths may contain hair, teeth, 
or in fact fragments of almost any of the tissues of 
the body. A case is on record where the surface of 
the tumor was covered with normal skin. 

Lipoma. This is the ordinary fatty tumor such 
as may be found in any part of the body. It is com- 
posed of a mass of fat cells held together by connect- 
ive tissue. It is more likely to spring from the upper 
part of the rectum and owing to its great elasticity 
the pedicle may be drawn out to a surprising length. 
It is said that the pedicle may contain a process of 
peritoneum which makes its removal somewhat 
dangerous. 

Cystoma. This is an exceedingly rare form of 
rectal neoplasm. The writer in quite an extensive 
practice has never seen a case. That such a growth 
might occur in this place is not to be doubted as they 
are possible in almost any part of the body. 

Enchondroma. This is a firm, tough growth, 
much resembling cartilage. These are not often found 
but cases have been reported by Van Bueren, Dolbeau 



152 



TREATMENT OP RECTAL, DISEASES 



and others. Kelsey says, "Cartilaginous tumors of 
the rectum proper are of exceeding rarity, and when 
found they are generally the result of a secondary 
change in a tumor primarily glandular, and do not 
therefore present the well known characteristics of 
the typical enchondroma." 

Angioma. This is an erectile or vascular growth 
and is very much the same as a venous nsevus or 




Fig. 49. Syphilitic condylomata. — (Kelsey.) 



macula materna. It consists of dilated veins and 
capillaries held together by submucous tissue. It has 
much the appearance of the capillary hemorrhoid 
but is more in the nature of a growth or tumor and 
does not bleed easily as the latter does. 



NON-MALIGNANT GROWTHS 153 

Treatment. All of these tumors may be removed 
by ligating the pedicle and cutting them off. Care 
must be exercised that the pedicle is not broken off 
in the effort to pull the tumor down so that the liga- 
ture may be placed. Should it be impossible to get 
the tumor out far enough to place a ligature around 
it, the snare may be used. This will cut through the 
pedicle and as a rule no hemorrhage will follow, or 




Fig. 50. Snare for polypus and other small growths. 

at least not enough to be feared. If the operator 
thinks hemorrhage likely and cannot apply a ligature, 
the pedicle may be grasped with a pair of long curved 
forceps, the tumor cut off and the stump cauterized. 
In some instances the tumors have been forced out 
by the action of the sphincter muscle with such force 
that the pedicle was torn off and spontaneous cure 
would result. No after treatment is necessary except 
ordinary surgical cleanliness. 



. CHAPTER X. 

PROCTITIS AND SIGMOIDITIS. 

Acute and chronic inflammation of the different mu- 
cus membranes of the body are very common and 
manifest their presence in different ways according 
to the part affected, and whether acute or chronic. 

The causes that produce the disease in one place 
will do so in another. A sudden chilling of the body 
may cause a so-called cold in the head and sleeping 
on cold, damp ground may cause a proctitis, which, if 
left untreated, may become chronic and we have the 
chronic diarrhoea so often found among elderly people, 
especially old soldiers. 

Then again we may have a specific inflammation of 
the rectal membrane generally due to indirect causes, 
as diptheria, gonorrhoea, etc., accidentally carried from 
some other part of the patient's body to the anal or 
rectal membrane by means of instruments, fingers 
or syringe nozzles, or by the discharge in females flow- 
ing over the parts. 

Among the causes in addition to those already 
mentioned, probably the most common one is trauma- 
tism, either from within or without. From within, 
serious injury from substances swallowed, as pins, 
fish bones and other foreign substances. All such 
things will pass through the stomach and small and 
large intestine without difficulty but lodge in the rectal 
pouch and set up an inflammatory process that results 
in a general proctitis or possibly an abscess. 

154 



PROCTITIS AND SIGMOIDITIS 155 

I have frequently taken such things from abscess 
cavities in this region. The disease may also be caused 
by the prolonged retention of hard dry, impacted, 
fecal matter, which is very irritating. Those causes 
which act from without are contusions and punctured 
wounds. It is not very uncommon to have the bowel 
wall punctured by the rough use of instruments or 
the finger in making an examination. In a recent 
issue of the Journal of the American Medical Associa- 
tion, Howard Kelley cites several cases where the 
wall of the bowel was punctured by the examining 
finger. This is more likely to occur in old people. 

In case such wounds are uncared for a proctitis 
and peri-proctitis would result that might be fatal. 
Kelly says such tears should be repaired by opening 
the abdomen and stitching from the peritoneal side. 
Owing to their being so low in the pelvis, it seems 
to me that this would be extremely difficult to do. 
In the chronic form of the disease, in addition to the 
rectal inflammation, we almost always have an exten- 
tion to the sigmoid and often the whole descending 
colon may be affected. 

In the acute form the pain is very great and is 
accompanied with tenesmus and considerable con- 
stitutional disturbance. There is a constant feeling: 
that there is something more in the bowel, even after 
the patient has just left the commode, but this is due 
to the swollen mucus membrane. 

When the disease becomes chronic there is not 
much pain except on deep pressure over the sigmoid. 
The desire to go to the stool, while not constant as in 
the acute form, is still very troublesome and there may 
be from ten to twenty bowel movements daily. This 
occurs more in the morning than any other part of 
the dav and it is net uncommon to have four or five 



156 TREATMENT OF RECTAL DISEASES 

movements in rapid succession containing" nothing 
but bloody mucus or clear mucus resembling jelly, to 
be followed by a solid stool. The patient may then 
pass the rest of the day with but little discomfort. 

In its early stages it is difficult to diagnose this 
disease from cancer of the sigmoid but as the latter 
is essentially chronic while cancer runs its course in 
two or three years and as the sigmoiditis does not 
as a rule fall into the Doctor's hands until it has run 
for some time the diagnosis is not hard to make. 
A microscopical examination of the discharge should 
be made to differentiate between the common inflam- 
mations and amebic dysentery. As the ameba are not 
active in cold solution the examination should be 
made while the matter passed is still warm. 

In the chronic form of the disease the membrane 
of the sigmoid when examined through the sig- 
moidoscope has a very dark appearance and looks like 
fresh raw beef, and in some instances blood may be 
seen oozing from the bowel wall. 

Treatment. In the acute form this consists of 
rest to the inflamed part, a carefully selected diet and 
the use of mild, antiseptic, astringent solutions. 

The one great difficulty in treating proctitis is 
lack of drainage. The products of inflammation are 
retained behind a tight sphincter/ ( muscle and the 
greater the inflammation the more firmly does the 
muscle contract. This is true to so great an extent 
that often it is only with the greatest difficulty that a 
bowel movement may be had or an irrigator introduc- 
ed. In such cases the patient had better be put under 
an anaesthetic and the sphincter divulsed. 

In punctured wounds where the bowel wall is torn 
and pus has formed it may be necessary to cut the 



PROCTITIS AND SIGMOIDITIS 157 

muscle posteriorly so that proper drainage may be 
obtained. 

There is no one thing that assists nature so much 
in bringing about a cure in a diseased organ as rest. 
For this reason, in acute cases the patient should be 
kept in bed and fed only highly concentrated food, 
such as will leave practically no residue to pass away. 
In fact if almost no food is given for a few days it 
will greatly assist in the cure. Another reason why 
the recumbent position should be insisted upon is that 
the rectum and sigmoid are drained by the middle 
and superior hemorrhoidal veins which have no valves 
and go direct to the liver through the portal system, 
and when the patient is standing the weight of this 
entire column of blood has to be lifted by the heart 
while, if he is lying down, gravity will greatly assist 
in keeping the parts free from excessive congestion. 

In the acute form it is not common to have any 
extension to the sigmoid and for this reason any 
injection used need not be forced above the rectal 
pouch. A double current rectal irrigator should be 
used or if this is not at hand an ordinary soft rubber 
catheter may be introduced with the syringe nozzle 
for the return flow. By shutting off the outflow tube 
the rectal pouch may be filled to its fullest capacity. 
The remedy that has given me the greatest satisfaction 
is Fl. Hydrastis in 25% solution. Weak solutions of 
zinc and copper are useful, as are also the new prepara- 
tions of silver, especially Argyrol in from 5 to 10% 
solution. Xitrate of silver should not be used in acute 
proctitis except in very weak solution. In order to 
control the constant desire to empty the bowel some 
local opiate is needed and nothing acts better that two 
or three ounces of starch water to which has been 



158 TREATMENT OF RECTAL DISEASES 

added from 10 to 20 drops of Tr. Opii. to be repeated 
as found necessary. 

Specific proctitis is not often seen and is generally 
due to gonorrhoea. The line of treatment should be 
the same as that followed in treating the disease in 
other localities. Irrigations with large hot permanga- 
nate solution from 3 to 5% in the early stages and 
later one or two ounces of Argyrol solution, injected 
into the bowel twice daily and retained. 

In the later stages of the disease more strongly 
astringent remedies should be used, and a good one 
is a mixture of Zinc Sulph., Bismuth Carbonate, Fl. 
Hyrastis, and water. 

In treating the chronic form of the disease we 
meet with a more difficult problem, as the sigmoid 
and often the descending colon are affected and irriga- 
tions must be forced beyond the rectal pouch. Most 
writers on this subject advise the use of the long rectal 
tube but I have found from experience that it is 
exceedingly difficult to introduce this instrument into 
the descending colon. I have used the utmost care in 
trying to do this and have congratulated myself that 
the tube was in almost its full length only to find that 
it was coiled in the rectum. 

My plan for irrigating the descending colon is 
as follows : — Have the patient lie on his back with the 
hips well elevated. Have the water very hot and the 
irrigator not more than two feet above the table. Use 
a short nozzle, not more than three inches long. Let 
the water run very slowly and if the patient says that he 
cannot hold it, stop the flow until the desire for an 
evacuation passes away and then start it again. It 
is only the first few ounces that cause a desire for an 
evacuation and as soon as the water begins to flow into 
the sigmoid this will not be felt, as a rule. If the 



PROCTITIS AND SIGMOIDITIS 159 

sphincter is very lax, push the syringe nozzle through 
a small roller bandage and into the bowel and sufficient 
pressure can be made against the sphincter to prevent 
the discharge of the water. By using a double flow 
nozzle and compressing the outflow tube at intervals, 
the colon may be flushed with sterile water or salt 
solution after which such medicated solutions as may 
be thought best may be run into the bowel and some 
of it allowed to remain. This should not be done more 
than two or three times a week at first and later not 
more often than once a week. In case there is much 
blood in the discharge, a solution of silver nitrate seems 
to do more good than any other remedy. It should not 
be stronger than }4 of i% at first and may gradually 
be brought up to 2 or 3%. It should not be used more 
often than once a week and if it causes much pain it 
may be followed by the normal salt solution, but this 
should never precede the silver. Argyrol in 5 to 10% 
solution may be used with good results. 

In case amebic dysentery is present the solution 
should be used cold as the ameba cannot live in a low 
temperature. Tuttle claims to have cured several 
cases with ice water. A line of treatment which con- 
sists mainly in giving large doses of Epsom salts has 
proven very successful, mainly by keeping the colon 
clear of irritating material. The constant cathartic 
action of the drug is very depressing to the general 
health and really accomplishes no more than irrigation 
with salt solution. 

Great care should be taken with the diet and only 
the most concentrated and nutritious food given. Tea, 
coffee, and all alcoholic drinks should be prohibited. 
The treatment in the chronic form of the disease is 
necessarily tedious and requires considerable time but 
if carried out faithfully will generally result in a cure. 



160 TREATMENT OF RECTAL DISEASES 

Should it be impossible to bring about a cure by the 
methods outlined a colostomy may be resorted to, and, 
by diverting the fecal current, give the bowel complete 
rest, or an opening may be made in the ceacum and 
by means of a catheter the treatment may be carried 
on both from above and below as recommended by 
Gibson. 



CHAPTER XI 
NON-MALIGNANT STRICTURE. 

Stricture is a comparatively rare disease and yet 
it occurs more often than it is supposed to because 
the physician in general practice does not recognize 
it and treats the patient for constipation, which is one 
of its symptoms. 

It occurs more often in women than men and is 
most common between the ages of twenty and fifty. 

There are two general classes of stricture, the con- 
genital and acquired. The former will be considered 
in the chapter on congenital malformations. I will 
discuss briefly some of the causes of stricture, as in 
this way a better understanding may be had of the 
treatment. 

Spasmodic Stricture. Whether it is possible for 
involuntary muscular fibre to spasmodically contract 
so as to cause a narrowing of the calibre of the bowel 
has not been fully decided. I am of the opinion that 
this may occur as a result of some irritation such as 
an irritable ulcer or some reflex action from the genito- 
urinary organs such as might be caused by a stone 
in the bladder, but that it could occur without some 
such cause I do not believe. Air. Harrison Cripps says 
that any irritation which causes a continual shortening 
of muscular fibre might in time cause the muscle to 
become permanently shortened and thus cause a strict- 
ure. In urethral disease it is often found nearly im- 
possible to pass a sound because of the spasmodic con- 
traction in front of the instrument. 

If the canal is perfectly healthy this does not occur 
as a rule. The same thing may take place in the bowel. 
A patient with an irritable ulcer may find that when he 

in 



162 TREATMENT OF RECTAL DISEASES 

undertakes to have a bowel movement the sphincter 
muscle will contract in spite of all that he can do and 
a temporary spasmodic stricture is the result. The 
above, it seems to me, is the true explanation of spas- 
modic stricture and while it does exist it is not a true 
stricture but only a temporary contraction due to re- 
flex irritation. 

Pressure From Without. This is not strictly 
speaking a stricture at all but is a narrowing of the 
bowel because of the pressure of some tumor or adhes- 
ive band on the outside. Probably the most common 
cause of obstruction is a badly retroverted uterus. Any 
large tumor in the pelvis may cause sufficient pressure 
to produce a partial or complete closure of the bowel. 
A large pelvic abscess in females may do the same 
thing and the bands and adhesions that may occur as 
a result of such abscess or from operations in the 
pelvis may produce the same condition of affairs. 

Tubercular Stricture. This is quite rare and is 
probably the result of cicitrical contraction due to 
the healing of a tubercular ulceration. There is no 
way that I know of whereby sufficient tubercular de- 
posit could be lodged in the rectal pouch to cause a 
stricture, because it is the tendency of this kind of 
deposit to break down rather than to build up and 
before a sufficient quantity could be lodged in the bowel 
wall to cause a stricture, it would break down and 
cause a tubercular or so-called cold abscess. 

Traumatic Stricture. This really includes the in- 
flammatory form of the disease and is the cause of 
more strictures than any other single thing. That an 
injury of the lower end of the bowel could unaided 
cause a stricture, I very much doubt, but when we con- 
sider that these injuries are followed by a long inflam- 
matory process with much destruction of tissue and 



NON-MALIGNANT STRICTURE 



163 



cicitricial contraction it is easy to see how it may en- 
tirely occlude the calibre of the bowel. 

Any traumatism that sets up a proctitis may cause 
stricture, among which may be mentioned surgical 




STRICTlRt 
RECTliN 



Fig. 51. Annular stricture. 

operations, impacted feces, the introduction of foreign 
bodies, as is sometimes done by the insane, pressure 
by the child's head in labor, enemas of too strong 
caustics, as the injection by mistake of pure carbolic 
acid or concentrated solutions of corrosive sublimate. 
Stricture due to the too free use of the cautery at the 
junction of the skin and mucous membrane is not 
uncommon and I have seen almost complete occlu- 
sion of the bowel from this cause. This is a stricture 
of the anus and not of the rectum. 



164 TREATMENT OP RECTAL DISEASES 

Venereal Stricture. This is in my opinion limited 
almost entirely to syphilis in its late stages. It is 
said to be caused by gonorrhaea and chancroids but 
this is, I feel sure, a mistake. I do not wish to discuss 
the matter here but will only say that I never saw a 
case due to either of these causes in my own practice. 

As the years go by I am coming to believe more and 
more that our past opinions in regard to syphilis caus- 
ing rectal stricture are wrong. That it does do so, 
there is no doubt, but not to the extent believed by 
some. Allingham says that out of one hundred 
patients who had rectal stricture, a history of syphilis 
was traced in fifty two or more than half. While this 
may be true, I believe that some of the fifty-two would 
have had the stricture from other causes regardless 
of the syphilis. The fact that they had both at the same 
time was a mere coincidence. I believe that to say 
twenty-five per cent of all strictures of the rectum are 
due to syphilis, is more nearly correct. 

Stricture is caused by syphilis mainly by a gum- 
matous deposit in the submucous tissue and as a rule is 
deposited equally around the entire wall of the bowel. 

It may in this way be distinguished from cancer 
as the latter generally affects the bowel wall unevenly 
and projects more in some places than others. Another 
diagnostic point is the fact that if left untreated it 
kills in from three to four years while syphilis may 
last indefinitely. 

Symptoms and Diagnosis. Generally the first thing 
complained of is the ulceration which precedes the 
stricture but in case there has been no ulceration, about 
the first thing complained of will be constipation 
alternating with diarrhoea. The reason that these 
symptoms occur is that the fecal matter gathers above 
the strictured portion of the bowel and accumulates. 



NON-MALIGNANT STRICTURE 165 

there until by its irritating action it sets up a mild in- 
flammation and an acute diarrhoea is the result. After 
this the patient goes along very nicely for a while but 
gradually becoming more and more constipated and 
all the while increasing the amount of cathartic medi- 
cine that he takes until nature again starts the diarr- 
hoea. These attacks are repeated at infrequent in- 
tervals until the stenosis becomes so great that he 
seeks surgical aid. In some cases, because of the 
irritation above the stricture, an abscess will form and 
burrow to the surface somewhere on the buttocks, 
leaving a complete fistula through which the feces are 
nearly all discharged. Patients have been known to 
live for a long time with no other opening than this 
fistulous track through which the contents of the bowel 
could be passed. On the other hand fistulous chan- 
nels may form below the stricture. This is 
caused by the deposit of fibrous or gummatous matter 
in the bowel wall, which shuts off the blood supply to 
the parts below, resulting in local circumscribed death 
of the parts in small areas causing a breaking down of 
tissue and an abscess and fistula results. For reasons 
just stated, when a patient is seen with a fistula the 
bowel should always be examined for stricture. 
Probably seventy-five per cent of all strictures of the 
rectum are within reach of the finger and the diagnosis 
can easilv be made in this way. If the well oiled finsrer 
encounters an obstruction which it cannot easily pass, 
but having a small opening in the center, it is a strict- 
ure of some sort. The finger may be gently passed 
through the opening in many cases and in this way 
the extent of the strictured portion may be ascertained 
and whether the obstruction is in the bowel wall or 
from some pressure on the outside. 

In case the stricture is bevond the reach of the 



16G TREATMENT O? RECTAL DISEASES 

finger, the proctoscope should be used. No one, re- 
gardless of how expert he is, should base a diagnosis 
of stricture of the rectum on the inability to pass a 
bougie. It has been proven beyond question that a 
bougie will catch on the promontory of the sacrum or 
in the folds of mucous membrane in the hollow of the 
sacrum. The proctoscope will in nearly every case 
reveal the exact location of the stricture unless it is 
above the sigmoid in which case an exploratory opera- 
tion should be done. 

If the stricture is not complete and can be seen 
plainly through the proctoscope, an olive tipped whale- 
bone bougie may be carefully passed through the 
opening to ascertain its extent. Great care should be 
used to not puncture the bowel. 

In order to distinguish between benign and malig- 
nant stricture, the following table taken from Ball 
is very interesting*. 

NON-MALIGNANT STRICTURE. 

ist. Generally a disease of adult life. 

2nd. Essentially chronic and not implicating the 
system for a long time. 

3rd. The orifice of the stricture feels like a hard 
ridge in the tissues of the bowel. Polypoid growths, 
if present, are felt to be attached to the mucous mem- 
brane. 

4th. Ulceration of the mucous membrane may be 
present, but without any great induration of the edges. 

5th. The entire circumference of the bowel is con- 
stricted unless the stricture is valvular. 

6th. Pain, throughout the whole course, in direct 
proportion to the fecal obstruction and complained 
c* only during defecation. 

7th. Glands not involved. 



NON-MALIGNANT STRICTURE 167 

MALIGNANT STRICTURE. 

ist. Generally a disease of old age. 

2nd. Progress comparatively rapid and general 
cachexia soon produced. 

3rd. Masses of new growth are to be felt either 
as flat plates beneath the mucous membrane and the 
muscular tunic, or as distinct tumors encroaching 
on the lumen of the bowel. 

4th. Ulceration, when present, is evidently the 
result of the breaking down of the neoplasm; the 
edges are much thickened and infiltrated. 

5th. Generally one portion of the circumference 
is more obviously involved. 

6th. In the advanced stages pain is frequently 
referred to the sensory distribution of some of the 
branches of the sacral plexus, due to the direct im- 
plication of their trunks. 

7th. The sacral lymphatic glands can sometimes 
be felt through the rectum, enlarged and hard. 

Treatment. Much may be done in the way of pal- 
liation should an operation be refused or for any 
reason be thought not best. This consists mainly in 
keeping the bowel contents in as near a fluid condition 
as possible. Strong cathartics should never be given 
but laxatives are indicated. These should be varied 
to meet the indications of the case. The different 
mineral waters, compound licorice powder, malt with 
cascara, etc., are all useful. Pure olive oil with about 
one third glycerine added, while not greatly laxative, 
will, if given for some time, have a most excellent 
effect. 

Injections of water or oil do much good. The 
diet should be carefully regulated and the patient kept 
on milk, soup, soft boiled eggs and such things as 
leave but little residue to be passed away. 



168 TREATMENT OF RECTAL DISEASES 

In order to bring about a cure, more radical meas- 
ures must 'be used. The easiest method for the physi- 
cian in general practice, is gradual dilation with 
Wales rubber bougies. I believe that it is nearly 
if not quite impossible to bring about a complete cure 
in this way but with persistence and with a short period 
of treatment, occasionally, all through life many 
patients may be kept in pretty comfortable condition. 
This, combined with incision, is safe and will cure 
many cases, besides not requiring chloroform. Always 
use a bougie as large as will pass without pain or 
requiring the use of force. No good can be accom- 



Fig. 52. Wales rectal bougie. 

plished by pushing a large instrument through a strict- 
ure and it is liable to cause a rupture of the bowel and 
peritonitis. 

Having found the instrument that will pass easily 
the patient should be taught how to use it and instruc- 
ted to pass it through the stricture at bed time and 
leave it there for an hour or more. At the end of a 
week a larger size may be tried and if it passes easily 
it should be used for a week when a still larger one 
may be used. Should the sphincter become irritated 
from the passing of the instrument so often, it will have 
to be stopped for a while. Still it does no good to 
begin this treatment unless it can be continued for a 
long time and with persistence and vigor. Some object 
to allowing the patient to pass the bougie, because they 
might do themselves an injury. I am satisfied that a 
patient of ordinary intelligence may be taught to do 
this without danger. It is nearly impossible for them 
to come to the doctor's office every day and even, if 



NON-MALIGNANT STRICTURE 



169 



they did. he could not spare the necessary time. The 
stricture dilates much the same as a rubber band 
would do and for awhile will return to its original 
size as soon as the instrument is taken out but if kept 
stretched more or less constantly for a long time, 
absorption will take place and it will be of larger size 
than formerly. This mav be combined with incision or 




•Stricture 

RECTUM 



Fig. 53. Tubular stricture. 



internal proctotomy if the stricture does not extend 
too hisfh and involve too much of the bowel. This 
is done by dilating the sphincter through a speculum 
and cutting the stricture in one or more places down to 
the bowel wall, being careful to not cut too deep. This 
accomplishes at once what gradual dilatation would 



170 TREATMENT OF RECTAL DISEASES 

require months to bring about. It should be followed 
by constant dilatation so the cut surface will not unite 
and leave the stricture in the same condition it was 
before. The worst objection to this method is the 
poor drainage and unless great care is used the rectal 
cavity will become filled with pus and a proctitis and 
possibly an abscess will result. But if plenty of water 
with mild antiseptics are used, there need be no fear 
of this. In order to get good drainage, external proct- 
otomy is done in some cases. This consists in cutting 
all the tissues from the upper margin of the stricture 
to the coccyx. This makes a broad gutter-like wound 
that allows for drainage and free discharge of all bowel 
contents. It must fill in by granulation which takes a 
long time but the results are generally good. 

In case there is any reason to suspect syphilis 
large doses or iodide of potassium should be given 
and kept up for a long time, alternated with such other 
anti-syphilitic remedies as may be thought best. This 
will not remove the stricture but will prevent its 
further development. 

There is a remedy called thiosiamin, which is 
said to have the power of removing scar tissue from 
any portion of the body. Recently several cases of 
stricture of the pylorus, urethra, and rectum have been 
reported cured by this means. I have not had a chance 
to test it but shall do so at the first opportunity. A 
fifteen per cent alcoholic solution used hypodermically 
is the best. Begin with about eight drops at a dose 
and gradually increase to sixteen. It is not best to 
use the injection more than twice a week. It need 
not be injected at the site of the stricture but may 
be used on any part of the body. It will probably do 
as well to give it by the mouth but it is said to be 
somewhat irritating to the stomach. 



CHAPTER XII. 

WOUNDS AND OTHER INJURIES. 

The injuries most often met with here are incised, 
lacerated, punctured and contused wounds, both of the 
bowel itself and the surrounding parts. These may 
occur in various ways but the most common cause is 
contusions from falling on hard objects as stones, the 
edge of seats, etc. Should the object fallen upon be 
sharp, there may be a punctured wound. There may 
also be an injury from foreign bodies too long re- 
tained or from pushing a bougie or other instrument 
through the bowel wall or the rough use of the finger 
in examining the parts. As stated in another place, 
Kelly reports five cases where the bowel wall was 
perforated in using too great force with the finger. 
This is more likely to occur in old people whose tissuej 
are weak and easily torn. Several cases have been 
reported of puncture of the bowel wall, and injection 
into the peritoneal cavity of a pint or more of water 
or soap suds. 

There are many injuries to these parts in war, due 
to gun shot wounds, bayonet and sabre thrusts, etc. 
One of the most common causes of injury is from 
fecal impaction and foreign bodies. The former is 
apt to cause tears and abrasions from straining and 
the use of instruments in its removal and the latter 
from the same cause with the added danger of cuts 
from sharp edges or the breaking of glass, such as 
small bottles. 

Another class of wounds are those caused acci- 
dentally while operating on other organs, as prostate 

171 



172 TREATMENT OF RECTAL DISEASES 

or bladder. The bowel has been perforated by the 
old fashioned stiff bougie in trying to dilate a stricture. 
As this instrument is now seldom used these injuries 
are not found. 

Wounds that perforate the bowel wall are exceed- 
ingly serious if the opening is above the peritoneum 
because it allows fecal matter to pass into the peri- 
toneal cavity and peritonitis and death is the usual 
result. If the opening is below the reflection of the 
peritoneum, it will not be so serious but an abscess 
will result. There is apt to be infiltration of the sur- 
rounding tissue, severe bleeding and extensive sup- 
puration. 

The gravity of these injuries is the danger of peri- 
tonitis and the fact that there is such poor drainage 
to allow the products of suppuration to escape. 

In case the injury is confined to the internal parts 
and nothing shows from the outside, the real gravity 
may not be appreciated and the delay occasioned may 
cause the loss of the patient's life. Severe hemorrhage 
may go on with no escape of blood on the outside as 
it will pass into the upper part of the bowel and fill 
the entire large intestine. This condition will soon 
bring on collapse and all the symptoms of shock. 

Examination by the finger will generally show 
the extent of the injury and in case it does not, an 
anaesthetic should be given and the sphincter dilated 
until all the parts can be easily seen. Preparation 
should be made at the same time to operate if neces- 
sary. 

TREATMENT. 

In treating these wounds as before stated we must 
make some provision for drainage. If there is hemor- 
rhage going on which cannot be otherwise controlled 
the rectal cavity should be first throughly washed 



WOUNDS AND OTHER INJURIES 173 

out with hot water and then packed with gauze until 
the flow of blood stops. 

Of course if there is a tear in the bowel wall above 
the peritoneum the abdomen should be opened at once 
and the rupture closed from the peritoneal side. If 
this is not done the water used to wash out the bowel 
as well as the blood will at once pass into the peri- 
toneal" cavity. If the bowel contents have already es- 
caped into the abdominal cavity, it should be wiped 
out with sterile gauze and then with alcohol. 

Xature will take care of a good deal of foreign 
matter and where no pus is present it is best to not 
flush the abdomen. In case the wound is below 
the peritoneum, the abdomen need not be opened, but 
if there is a rupture of any importance through the 
bowel wall the sphincter should be divulsed or if need 
be cut and the opening closed. It is much better to 
divide the muscle posteriorly and thus get the wound 
in good condition and where it can be seen and pro- 
perly treated than to allow it to get into the foul con- 
dition that sometimes occurs. 

In dividing the muscle as suggested, we do not 
cut many of the muscular fibres, as they do not cross 
each other to a great extent, but pass directly back 
to their insertion into the coccyx. Xature will soon 
restore the divided parts to their former condition. 
The wound should be flushed daily with mild anti- 
septic solutions and the patient kept quiet and not al- 
lowed to get out of bed until nearly all inflammatory 
symptoms have passed away. 

In case a foreign body has lodged, in the rectal 
cavity it often requires a great deal of ingenuity to re- 
move it. As a rule, it is pushed in the easiest way 
and as soon as it passes the sphincter muscle the latter 
contracts behind it and everv effort made to remove 



174 TREATMENT OF RECTAL DISEASES 

it only seems to push it farther in. Should it be glass, 
there is the added danger that it may break and lac- 
erate the parts. If it is wood, it may be grasped with 
a pair of strong bone forceps and carefully removed. 
In some cases it may be of such a nature as to allow 
it to be cut to pieces and removed piece-meal. Rather 
than run the risk of mutilating the parts too much, 
the muscle had best be divided, which will allow the 
foreign body to be removed. 

In case it has passed into the sigmoid, an abdominal 
section should be done at once and it may be re- 
moved through this opening or pushed back and re- 
moved without opening the bowel. 



CHAPTER XIII 

PRURITUS ANI OR ITCHING OF THE ANAL REGION. 

This is the most intractable disease that the rectal 
surgeon is called upon to treat. It is often spoken of 
as a trivial matter, yet I have had patients who were al- 
most physical wrecks, due to loss of sleep, worry and 
nervous irritation. I believe that in its early stages 
it always has some well-defined cause which, if search- 
ed for and removed, will cure the disease. A little 
later, however, the terminal nerve filaments become 
affected, and even though the cause be removed, or 
has long since passed away, the itching will still re- 
main. The skin becomes thickened and parchment- 
like and the nerve endings seem to be pressed upon and 
constantly irritated. In these cases nothing will give 
permanent relief except the destruction of this altered 
tissue and the formation of new skin. There are sever- 
al ways of doing this, all differing in methods, but 
aiming at the same end. Of course if there is any 
cause that is keeping up the irritation, it should be 
removed. It would be very unwise to try to cure a 
pruritus due to eczema, pin-worms, fistula, hemorr- 
hoids, rectal catarrh, ulceration, etc., without first re- 
moving these. Having then, satisfied yourself that 
nothing is present but the changed condition of the 
skin and terminal nerve filaments, how is the best 
way to proceed? A plan that has given me good re- 
sults is the application of a ninety-five per cent solu- 
tion of carbolic acid to the affected skin. The epider- 
mis peels off in a few days, leaving a somewhat ten- 

175 



176 TREATMENT OF RECTAL DISEASES 

der surface that should be treated with soothing oint^ 
merits, such as the ointment of zinc oxide. After an 
interval of two or three weeks the acid should be 
put on again. This may have to be put on several 
times before the skin becomes natural. Sometimes 
there are large warty ridges almost resembling piles. 
I never waste time with these, but simply cut them 
off and let the space fill in by granulation. The inter- 
vening and all surrounding tissue is treated with the 
acid. This seems like rough treatment, and so it is, 
but it should not be forgotten that we are dealing with 
a most stubborn disease, and decisive measures must 
be adopted to bring about a cure. Some patients 
object, but the majority are willing to submit to any- 
thing that promises relief. After all, it is not so pain- 
ful, as the acid acts as a local anaesthetic, and while it 
burns somewhat, it is a comfort, as it stops the terrible 
itching. 

The following case illustrates the benefits of this 
method of treatment : 

Case — Mr. W., age forty, treasurer of an eastern 
Iowa count}', and a man of more than ordinary in- 
telligence, came to my office complaining of pruritus 
that was simply making life unbearable. The disease 
had troubled him for a long time, but was much worse 
at present than ever before. Examination showed the 
skin to be thick, parchment like, and lifeless, with 
several heavy folds that radiated from the anal apert- 
ure. I explained to him that as he could not remain 
for treatment, anything that I did must necessarily 
be pretty severe ; also that it would have to be kept 
up at home for a long time. He replied that he "did 
not care 'what I put on, as it would be a relief to what 
he was now suffering." I cut off all the redundant 
tissue and applied acid to the surrounding skin. I 



PRURITUS ANI 177 

gave him the zinc oxide ointment to use until the sore- 
ness had left, and told him to have his wife apply the 
acid and to keep it up as long as seemed necessary. 
I also gave him the following injection: 

Dist. Ext. Hamamelis 10 dr. 

Monsel's Solution 2 dr. 

Phenol Sodique , 6 dr. 

Glycerin 4 dr. 

Mix. Sig. Inject one-half teaspoonful in starch 
water at bedtime. 

He was warned against scratching, and told to 
forego all alcoholic drinks, excessive use of tobacco, 
rich meats, highly seasoned foods, etc. He continued 
this treatment for a long time and was rewarded with 
a complete cure. After six years there has been no 
return of the disease. 

In cases that are caused by a vegetable parasite I 
have made use of pure sulphurous acid with good 
results. It is generally used in solution, but I have 
found that it is better to use it full strength. It is 
quite painful, but one application is all that need be 
made, as it will destroy any living parasite that may 
be present. 

The application of very hot water followed by 
citrine ointment applied freely on gauze over which 
is tightly bound a pad that makes considerable pressure 
will often give relief so that the sufferer may obtain 
a good night's rest. 

In fact the citrine ointment is the best single agent 
with which I am familiar to bring about a permanent 
cure. 'When used persistently for a long time it will 
in many instances bring about permanent relief. 



178 TREATMENT OF RECTAL DISEASES 

It is said that French surgeons use a sharp curette 
and scrape away all of the diseased skin, thus bring- 
ing about the same condition that we do by removing 
it surgically and bringing the edges together with 
sutures. The carbolic acid does the same thing only 
in a slower manner. Kelsey uses the white hot cautery 
passing it lightly over all the affected parts. This, 
of course, is only another method of destroying the 
superficial layer of skin and allowing healthy tissue 
to take its place. It matters not what may have been 
the original cause of the disease or how long since this 
cause may have passed away there comes a time when 
the terminal nerve filaments are bound down by the 
deposit of fibrous matter produced by the irritation 
of scratching and nothing short of its complete de- 
struction or removal will bring about a cure. 

I believe that most of these cases originate from 
a catarrhal condition of the bowel and that if seen 
early enough, treatment directed to this condition if 
carefully carried out would cure the pruritus. Tuttle 
says, "Catarrhal diseases of the rectum and anus are 
among the most frequent causes : whether it be the 
atrophic or the hypertrophic form, pruritus is one of 
the commonest symptoms. The dry, brittle condition 
of the muco-cutaneous membrane about the anus, de- 
scribed as a symptom of pruritus ani, is nothing more 
or less than a part of the atrophic catarrh of the 
rectum and anus ; and that moist, sodden, whitish 
condition seen in chronic cases is the result of the 
hypertrophic type." 

It is well known by all who do rectal surgery that 
after hemorrhoid operations or any condition where 
there is a wound that discharges pus as it heals, there 
is a constant pruritus on all the surrounding tissue 
owing to its being constantly irritated by the discharge. 



PRURITUS ANI 179 

In some cases there may be discovered just inside the 
sphincter muscle an ulcer, which constantly discharges 
an irritating matter that is responsible for the whole 
trouble. As before remarked, even though the cause 
is removed, the skin in many patients has become so 
diseased that it must be completely removed by some 
method in order to bring about a cure. 

Other causes that should be searched for, are con- 
stitutional diseases, especially diabetes, rheumatism, 
gout and all the conditions that go under the name 
of uricemia. There seems to be an irritant in the 
blood that causes cracks and fissures at all the muco- 
cutaneous junctions and pruritus ani and vul-vi which 
are very troublesome. 

These people are generally affected with eczema 
and the skin seems dry and scaly especially about the 
scrotum on the breast and about the ears and hair. 

Certain errors of digestion as well as certain artic- 
les of food may start an attack of pruritus. Coffee 
has seemed to me to be more harmful than any other 
article of diet and will alone produce the disease in 
certain persons. All of these things should be searched 
for and if found, given careful attention. I absolutely 
refuse to treat a person who it in the habit or drinking 
any form of alcohol. 

As a rule the treatment must be long and tedious 
and unless the patient will make every effort to assist 
in bringing about a cure I refuse to treat him. 

There are many formulae that are used with more 
or less success, a few of which are here given. Tuttle 
speaks highly of the following : — 

Ac carbolici 2 dr. 

Ac. salicylici I dr. 

Glycerine I dr. 



180 TREATMENT OF RECTAL DISEASES 

M — Sig. — Apply with camels hair brush after 
bathing with hot water. 

Matthews recommends 

Campho-phenique t I dr. 

Glycerine i oz. 

M. — Sig. — Apply after using hot water and repeat 
frequently if necessary. 

In cases where there are fissure like cracks at the 
junction of the skin and mucous membrane, Cripps 
recommends the following: — 

Ext. conii , . I dr. 

Ol ricini I dr. 

Lanolini ' I dr. 

M. — Sig. — Apply frequently. 

An ointment of chloroform as follows acts nicely 
in many cases. 

Chloroform I dr. 

Ungt. petrolati I oz. 

M. — Sig. — Apply frequently. 

This must be but up in a wide topped bottle and 
kept tightly corked, as otherwise the chloroform, will 
soon evaporate. 

Where the parts are too moist the treatment is 
often assisted by the use of powders that will absorb 
the moisture. Plain starch has given good results 
in many cases. Dry calomel many times is very use-" 
ful. 



PRURITUS ANI 181 

The following has given good results : — 

Camphor 2 dr. 

Ac. carbol gtt.15 

Crete Precip (English) oz.2 

Zinc oxide pulv dr.2 

Perfume q. s 

M. — Reduce the camphor with alcohol and mix 
the others through bolting cloth of one hundred meshes 
to the inch. 

I have operated under chloroform three times by 
removing a section of the skin for about an inch on 
each side of the anus and then undermining the sur- 
rounding skin and drawing it together to cover the 
denuded surface and stitched it to the mucous mem- 
brane of the bowel. 

In two cases I secured good results and the other 
was lost sight of. This procedure was suggested 
to me by my friend, Dr. Hamilton of this city, and 
as a means of last resort I believe it to be very val- 
uable. I intend to make further use of it as oppor- 
tunity arises. 

Patients should always be told not to scratch the 
parts, although this warning is seldom heeded. If 
the itching is so severe as to interfere with sleep, have 
them use hot water, gradually increasing the tempera- 
ture, until it is nearly scalding. In case this is not 
sufficient to give relief, an ointment of chloroform 
one dram to one ounce of cosmoline, may be applied. 
A weak solution of carbolic acid in water and glycerine 
will often give relief when all else fails. The following 
mixture is a most excellent one : — 



182 TREATMENT OF RECTAL DISEASES 

Sodium hyposulphate I oz. 

Carbolic acid . . . y 2 dr. 

Glycerin i oz. 

Aqua dest 3 oz. 

Mix. Sig. Apply frequently on compresses. 

Also : — 

Cocaine 2]/^ gr. 

Ext. rhatany 15 gr. 

Ext. hamamelis 7^ gr. 

Cosmoline 5 dr. 

Mix. Sig. Apply freely. 

Dr. Buckley recommends the following, and I can 
testify to its merits : — 

Ungt. picis 3 dr. 

Ungt. belladon 2 dr. 

Tr. aconit rad ]/ 2 dr. 

Zinc oxide 1 dr. 

Ungt. aqua rosa 3 dr. 

Mix. Sig. Apply freely. 

I know of no disease that will so tax the skill and 
ingenuity of the physician as this, and in all cases the 
patient should be made to understand that in order 
to be cured, he must be willing to do all in his power 
to aid the treatment. Many times the cure seems to 
be accomplished when a relapse will occur which is 
very discouraging to both the patient and physician. 



CHAPTER XIV. 

CONGENITAL MALFORMATIONS. 

The physician in general practice does not often 
meet with malformations of the lower end of the 
bowel ; many going through a long life-time of prac- 
tice without seeing a case. It is said that there is 
only about one case of malformation in four thousand 
five hundred thirty-eight births. While this is a small 
proportion, no one knows when the next one will 
happen or who will have charge of the obstretrical 
case in which it occurs. When a child is born it should 
be carefully examined to see whether or not it is phys- 
ically perfect. If not, measures should be adopted 
as soon as possible to correct the malformation if it 
can be done with any reasonable hope of success. 
If there is not a fair chance of correcting the deform- 
ity so that it will leave the child in nearly a natural 
condition, it had better be let alone. I do not believe 
that under any conditions an artificial anus should 
be made except as a temporary expedient. The laity 
do not understand the gravity and seriousness of the 
matter or the terrible condition in which the child 
must pass, not only its childhood, but probably a long 
life. It had better be allowed to die in infancy, and, 
if the parents are sensible, and the matter is explained 
fully to them, they will agree that this is to be pre- 
ferred. 

There are, however, a few conditions that may 
be remedied without much difficulty and the child 
left in a nearly natural condition. 

183 



184 TREATMENT OF RECTAL DISEASES 

The first one is a simple narrowing of the natural 
calibre of the bowel without occlusion. This is near- 
ly always overlooked and no doubt many go through 
life without its being discovered unless there is con- 
siderable narrowing of the bowel. It generally occurs 
in the annular form and nature will often overcome a 
great deal of it. The only symptoms in most cases 
will be obstinate constipation. If the stricture is quite 
tight it will produce all the symptoms of intestinal 
obstruction in other localities. It is not hard to diag- 
nose, as the narrowing is always near the outside and 
may be felt by digital examination. 

The treatment consists in gradual dilatation, if there 
is enough opening to allow this to be done. If not, do 
an internal or external proctotomy as directed in the 
chapter on stricture. 

The next form is where the opening is closed by 
a membrane stretched tightly across the anus. This 
is the simplest form of malformation and the easiest 
remedied and yet it will cause the death of the child 
unless attended to. Sometimes there is a very small 
opening at one side, sufficient to allow the discharge 
of meconium and liquid feces but when more solid 
substances attempt to pass, a complete obstruction 
occurs. The membrane will usually bulge outward 
so that the actual condition is easily recognized. The 
membrane should be cut in both directions across the 
center. The flaps left will shrivel up and disappear. 

The next form is where there is an entire absence 
of the anus and the rectum ends in a blind pouch 
somewhere in the pelvis. In this case there is no way 
to tell just where the lower end of the bowel actually 
is. It may be very nearly in its normal position and 
on the other hand, it may be a long way off, or it may 
end in the vagina or bladder. It is useless to cut 



CONGENITAL MALFORMATIONS 



185 



blindly into the place where the rectum ought to be, 
hoping by mere chance to find it. The better way is to 
make an opening in the abdomen at the proper site 
for an artificial anus, bring up the sigmoid and make 
a small puncture in it through which a catheter or 
large bougie may be passed. By pushing this care- 
fully down into the lower portion of the sigmoid, 
if the lower end is anywhere near its proper place, 




Fig. 54. Showing rectum ending in a blind pouch. (Kelsey), 



it can be felt by pressure from the outside, and will 
serve as a guide upon which to cut and the bowel may 
be found and brought down and fastened in its pro- 
per place. After it has been found and loosened so 
it will come down properly it should be secured by 
a ligature and then drawn back through the abdom- 
inal wound so the opening in the bowel through 
which the bougie was passed may be closed. After 



186 TREATMENT OF RECTAL DISEASES 

this is done the lower end is carefully drawn down and 
stitched in the perineum as near where the natural 
opening should be as possible. 

In case the bougie does not locate the lower end 
of the bowel in a place where it may be drawn down 
properly, an artificial anus may be made at the site 
of the original incision provided the parents desire 
that this be done after having the matter fully explain- 
ed to them. 




Fig. 55. Rectum ending in a blind pouch; anus normal. 

(Kelsey). 

The next form is where the rectum ends somewhere 
in the pelvis as just stated and the anus is normal but 
there is a distinct separation of the two ends. The 
septum is generally within easy reach of the finger 
and sometimes fluctuation may be felt in the lower 
end of the upper segment. There is no use of trying 
to operate on a case of this kind unless it is nearly 
certain that the two ends are close together. In this 



CONGENITAL MALFORMATIONS 



187 



case the coccyx and possibly a portion of the sacrum 
must be removed and the two ends dissected out and 
united. When one considers the extreme smallness 
of the space in which he has to work, the difficulties 
to be overcome are at once recognized. There is 
only about an inch space between the tuberosities of 
the ischium and the distance between the 1 pubes and 
coccyx is not much greater. 

There are several other malformations that might 
be considered but those mentioned are the ones most 
often met and the rest will not be discussed in detail. 
I wish to say, however, that w T here the rectum ends 
in the bladder, vagina or urethra, I consider the case 
absolutely hopeless. 




Fig. 56. Showing rectum ending in the bladder. (Kelsey). 



The trocar should never be used under any cir- 
cumstances, as it is extremely dangerous. There is 
not one chance in a thousand that it will go into the 



188 TREATMENT OF RECTAL DISEASES 

right place and it may enter the bladder or so injure 
the peritoneum as to cause death. 

It is argued by some that a colostomy should be 
done as a preliminary operation and when the child 
becomes older so that it can withstand the shock of 
more severe operations, a search should be made in 
the perineum for the lower end of the bowel. This 
would allow the use of the bougie or sound to assist 




Fig. 57. Rectum ending in Glans Penis. (Kelsey). 

in finding the termination of the lower end and give 
a definite point upon which to cut. There is good 
reasoning in this argument, as in addition to the in- 
creased strength of the patient it allows the attachment 
of the bowel in the perinum to heal without fecal 
matter passing over it and primary union may be 
expected. After this has occurred the artficial anus 
may be closed. 



CHAPTER XV 

THE DIAGNOISIS, SYMPTOMS AND TREATMENT 
OF RECTAL CANCER. 

This disease is most often seen in adult life. It 
rarely occurs before thirty, and hot often after sixty 
years of age, although cases are reported as occurring 
in children as young as six years. 

The malady affects males somewhat more often 
than females, and seems to be due in man}' instances 
to hereditary predisposition. 

The life of a person afflicted with rectal cancer 
is usually destroyed in three or four years from the 
beginning of the disease unless early operative in- 
terference is had. 

In a work of this kind it is not necessary to go 
into the classification, as the general features are so 
nearly identical in all that a person who is able to 
recognize one form will do so with the others. 

As about one-fourth of all cancers occur in the 
lower nine inches of the colon, and as early and com- 
plete excision offers the only hope of a radical cure, 
the necessity of recognizing the disease in its early 
stages is important. 

As to the symptoms and diagnosis, I cannot do 
better than to quote from Coley, in the Twentieth 
Century Practice. 

Symptoms. — "Uncomfortable feeling of weight 
and heaviness in the pelvis, with ill-defined feeling of 
annoyance after defecation. As the disease progres- 
ses, the ill-defined symptoms assume a more definite 

189 



190 TREATMEN'i OF RECTAL DISEASES 

character, the feeling- of heaviness becomes one of 
distension, and the feeling of annoyance gives way 
to one of pain. The stools are more scanty and more 
frequent, and instead of well-formed movements por- 
ridge-like masses are passed covered with slime. Con- 
stipation alternates with diarrhoea. Later on the calls 
to stool become more urgent, and the dejecta are com- 
posed mostl) of mucous, pus, and a few scybalse, 
perhaps streaked with blood. A dozen or more times 
a day ineffectual efforts are made to evacuate the bow- 
els, temporary relief only being obtained by the passage 
of muco purulent matter, the sensation of fullness, 
however, remaining. If the growth is located at the 
anal margin, the control of the sphincter is lost early 
in the disease. 

"If the growth is located above the sphincter, loss 
of control comes on earlier, and seems to be due to 
nerve involvement. The nature of the pain depends on 
the location of the growth. If the sphincters are 
involved, the pain is intense, lancinating in character, 
and radiating through the perineum and down the 
thighs and legs. If the affection is seated in the upper 
part of the rectum or sigmoid, the pain is less intense, 
and severe only after the passage of feces. 

"The cylindrical celled or glandular type begins 
by invasion of the submucosa, the early stages being 
unattended by any discharge, only with bulging of 
the mucosa into the lumen of the bowel does any 
ulceration occur. Emaciation and cachexia may ap- 
pear early. The disease steadily advances, invading the 
contiguous organs. The bladder, prostate, and urethra 
in the male, and the vagina in the female, also the 
uterus and ovaries. Ulceration often causes false 
passages. 



RECTAL CANCER 191 

"Diagnosis. — The growth may often be seen at 
the verge of the anus ; it may be felt with the finger, 
or it may require various instruments to detect it. 
If the growth is at the margin of the anus, a hard, 
indurated mass with everted edges, possibly ulcerated, 
protruding above the surrounding surface. The anus 
is thickened and fissured here and there from loss of 
elasticity. The extent of the induration and the de- 
gree of constriction of the parts are in direct relation 
to the duration of the disease. This condition may be 
confounded with chanchroidal or tubercular disease, 
but the history and the presence of cartilaginous indur- 
ation, and the ease with which a specimen may be 
obtained for microscopical examination will generally 
lead to a correct diagnosis. If the growth is located 
in the rectum, but within reach of the finger, and 
ulceration has not occurred, great delicacy of touch 
is required. Later, when ulceration has occurred, it 
is difficult to determine whether the disease is or is 
not malignant. This, however, is important, as treat- 
ment depends upon the diagnosis, and the disease may 
be cured at this stage. 

"Carcinomatous ulceration presents to the touch 
a well-marked area of induration with well-defined 
irregular margins. The induration extends diffusely 
beyond the edges of the ulcer, gradually fading into 
the surrounding tissues. In other forms of ulceration, 
the contour is regular, the induration slight, and the 
edges of the ulcer flexible. 

"If the ulceration has existed a number of years 
and been submitted to the action of escharotics, the 
character may be changed, but the chronic history 
will aid in the diagnosis. When the disease involves 
the whole circumference of the bowel and encroaches 
on the lumen of the surrounding tissues, the examining 



192 TREATMENT OF RECTAL DISEASES 

finger easily maps out the difference between the 
healthy and diseased tissue. It recognizes the stricture, 
and by careful palpation, the mobility of the canal is 
determined. This feature should not be overlooked, 
as it permits the recognition of the involvement of 
surrounding organs. Should the stricture be too nar- 
row to readily allow the introduction of the finger, 
force should never be employed in an effort to get 
beyond the strictured gut, as the diseased tissues are 
very friable and may be ruptured. Such an accident 
would result in peritonitis and death. The rapidity 
of the course of this disease renders diagnosis at this 
stage easy. Xon-malignant ulceration usually gives a 
history of years of suffering and unattended by in- 
volvement of surrounding organs and general symp- 
toms of cancer. When the disease it too low in the 
pelvis to be palpated through the abdomen, and too 
high to be reached by the finger, the various specula 
must be used." 

Treatment. As operative interference will not 
be considered here, I will discuss briefly the palliative 
treatment. 

The patient should in all cases be made to under- 
stand the gravity of the malady with which he is afflict- 
ed, and be allowed to choose whether he will accept 
the risk of an operation, or wait patiently for the 
end, with such relief as may be had from diet, local 
applications, etc. 

I think as a rule this disease should either be let 
alone or entirely removed. The more it is meddled 
with and treated, the faster it will progress. Still there 
are some conditions that may be benefitted by treat- 
ment. One of these is where the cancerous mass is 
inclined to protrude and become raw and painful. 
Here the application of a paste of arsenite of copper 



RECTAL CANCER 193 

will give great relief. Again, should the rectal cavity 
become occluded by a mass resembling a fungus 
growth, as it does sometimes in the encephaloid varie- 
ty, it may be curetted out and the canal cleared. 

In case pain is severe, the milder forms of opium, 
preferably codein, may be used. Morphine should be 
reserved for later use when the pain is often very 
great and large quantities are required. 

The diet should be very nutritious and composed 
of such things as leave but little residue to be passed 
off. In fact, the patient should be put on an invalid 
diet, composed of milk, eggs, soups, liquid peptonoids, 
cod liver oil, etc. The latter is especially useful as 
it is a food and is very soothing to the mucous mem- 
brane of the bowel. I think no article of diet so near- 
ly fills the indications as milk. Many persons think 
they cannot drink milk, but they can learn to like it, 
and by the addition of crackers or some of the many 
cereals now on the market, it will be nearly all the 
food needed. A moderate amount of fruit may be 
added for variety. 

The bowels should be moved daily without strain- 
ing. Should there be difficulty in this regard, some 
of the mild alkaline waters may be taken. If necessary 
the patient should be instructed to pass a small soft 
rubber rectal tube and wash out the bowel daily with 
warm water. 

There are three things connected with this disease 
that call for a colotomy and the formation of an artifi- 
cial anus, viz. : First, pain. Sometimes this is so great 
that the daily passage of fecal matter over the ulcerated 
surface' is simply unbearable, and the bowel contents 
must be directed along another course. Second, hem- 
orrhage. The constant tearing open of exposed blood 
vessels will in some cases soon cause death if not 



194 TREATMENT OF RECTAL DISEASES 

stopped. It will usually cease when the artificial 
opening is made. Third, diarrhoea. This, in many 
cases of cancer, is so severe that the patient will, if 
allowed, be on the commode most of the time. Colo- 
tomy is the only thing that will give relief. 



CHAPTER XVI. 

THE REFLEX ACTION OF RECTAL DISEASES. 

In the study of diseased conditions of the human 
body it is essential to investigate carefully in order 
to determine whether the subjective symptoms are 
actually located where the patient thinks they are, 
or if the real disease is in some distant organ or tissue, 
and only carried or reflected to the painful or dis- 
ordered part. 

After having made a careful study of rectal diseas- 
es, I feel confident that many functional disorders 
and painful manifestations result therefrom that are 
referred by the patient to other organs or parts of 
the body. 

In this discussion I include the rectum, anus and 
sigmoid flexure, and also the parts surrounding them. 
In studying the anatomy of the parts we find a greater 
nerve supply than in almost any other part of the body. 
The principal nerve supply comes from the internal 
pudic, the fourth sacral, and the posterior sacral. 
There is also an intimate connection with the sym- 
pathetic nervous system. Many large ganglia are 
also to be found in this region, thus uniting the great 
nervous systems, the general and the sympathetic. 

The blood supply is also very great. The arterial 
supply comes from many sources, thus affording al- 
ways a large amount of blood thrown into the parts, 
while the veins are not so plentiful, and having no 
valves, often allow the parts to become congested. 

195 



196 TREATMENT OF RECTAL DISEASES 

This congested condition combined in many cases 
with constipation, and the free use of purgatives, 
especially those of the class to which aloes be- 
long, keep the nerve supply in a constant state of 
irritation or hyperactivity. This condition is much 
more manifest when there exists an actual lesion, as 
an ulcer, fissure, proctitis, etc. Then it is that we see 
in many cases reflex symptoms manifest. It is a pe- 
culiar fact that the reflex symptoms manifested are 
not of the same nature as the causes that produced 
them. For example, a rectal abscess may produce 
symptoms of lumbago. Catarrh of the sigmoid is 
often treated for gastric indigestion, etc. 

In order to produce a reflex action there are four 
things essential, viz. : First, a point of irritation which, 
in pathological cases, may be an ulcer, abscess, foreign 
body, etc. Second, a line of transmission to a nerve 
center, or an afferent nerve fibre. Third, the nerve 
center, which may be the cord or a ganglion connecting 
the general with the sympathetic nervous system, and 
which may affect either the motor or sensory nervous 
system. Fourth, a return line or efferent nerve fibre 
which would ordinarily return the effect or result to 
the spot from whence it originated, but in the case of 
a reflected action, would conduct it to some other part 
of the body. 

It is difficult to account for the fact that certain 
effects are caused by a given pathological condition 
in one case, while the same condition in another case 
will cause a different effect. It seems to be accounted 
for only on the ground that certain nerve centers are at 
that time in a more exalted state of activity than others, 
and consequently any irritation is more easily appre- 
ciated. This is often seen in cases where a rectal 
abscess will, in one case, cause spasm of the urethra, 



THE REFLEX ACTION OF RECTAL DISEASES 197 

and in another lumbago or sciatica ; or where a bad 
case of hemorrhoids with prolapse will, in one case, 
cause vertigo, and in another cough, loss of flesh, and 
symptoms of phthisis. Yet that these results are seen 
can be verified by arry careful observer. 

In a moderately severe case of hemorrhoids that 
came under my care about two years ago, the patient, 
a traveling salesman, was in an extreme state of nerv- 
ous debility, and greatly emaciated. He had a worn, 
despondent expression, and was much discouraged. 
An operation effected a complete cure, and when I 
next saw him, some six months later, he had not only 
gained twenty-five pounds in weight, but had lost the 
despondent look and crabbed temper. His nervous 
system was entirely restored to its normal condition. 

Matthews, in his work on rectal diseases, describes 
a case that I will outline briefly. A man came under 
his care who had been an invalid for about a year. 
He began by erratic pains, loss of flesh, and general 
debility. His nervous system was badly deranged. 
His physician diagnosed his case as malignant, but 
could not tell where the cancerous disease was located. 
He rapidly grew worse, until he was reported to be 
in a dying condition, having settled his business pre- 
paratory to his passing to the great beyond. Being 
troubled with a great deal of pain in the rectum, to- 
gether with a persistent diarrhoea, Dr. M. was called, 
who made an examination and found an ulcer. The 
sphincter was divulsed, the ulcer scraped and irrigated, 
and the malignant disease disappeared, never to return. 
The man made a complete and uninterrupted recovery. 

Dr. Louis Bosher described in detail, before the 
West Virginia Academy of Medicine, a case which was 
diagnosed and treated as intestinal consumption, and 
the patient was reduced to such an extreme state of 



198 TREATMENT OF RECTAL DISEASES 

emaciation that death was considered only a matter 
of a few weeks. Almost by accident a rectal ulcer 
was discovered and treated. The patient at once began 
to improve and entirely recovered. 

The three cases just detailed I would classify as 
types of a general reflex action rather than a localized 
one ; that is, they have their effect on the entire nervous 
system, or at least on several important centers, in- 
terfering with the functions of important organs or 
glands, or in other indirect ways lowering the vitality 
and power of organs whose normal state of functional 
activity is essential to the life of the body. These 
cases are just as truly reflex in character as the ones 
that follow, although the pathology in the latter was 
confined to one spot instead of being of a more general 
nature. 

A man about forty years of age was taken with 
severe pain in the lumbar region. This became so 
severe that he had to go to bed. His physician diag- 
nosed his case as one of lumbago, and treated it as 
such. After lying in bed a few days he would be a 
little better and would get around with a cane, which 
would invariably start the pain again. This severe 
pain never left him unless under influence of morphine. 
This kept up for about six weeks, until, in one of his 
convalescent periods, he came to my office and said 
that he had a discharge from the rectum that kept the 
parts moist, and made him very uncomfortable. Upon 
examination, I found the opening of a very small 
sinus, which led up to an abscess behind the rectum. 
I opened it freely and let out two or three ounces of 
pus. From that minute the pain in his back left him. 
I do not know what caused the abscess, or why it 
formed so slowly. Neither did either of us think of 
there being any connection between the rectal trouble 



THE REFLEX ACTION OF RECTAL DISEASES 199 

and the back, but the cure of one instantly cured the 
other. 

A case is reported in which a small abscess just 
in front of the coccyx caused an almost unbearable 
neuralgia of the occipital nerve located in one small 
spot. This was treated in almost every way with no 
benefit until the abscess was opened and cleaned, when 
the pain left as if by magic, and did not return. 

These two cases are illustrations of localized re- 
flex action. Although the main features are the 
same in all cases, the last two do not have so general 
an effect as the ones that preceded them. 

In some cases, as the first one mentioned, there 
does not seem to be sufficient lesion to account for 
the serious symptoms present. There seems to be, 
in these cases, a leakage of nerve force, which, like 
the leakage of a steam boiler, by diverting the steam 
from its proper course, weakens the power and lowers 
the usefulness of the machinery. So in these cases, 
the vital element of nervous force is wasted and the 
power of physical resistance is lessened, thus weaken- 
ing the power of every organ and tissue in the body. 

The diagnosis in these cases is as a rule not diffi- 
cult, and is made by exclusion and examination. After 
the diagnosis is established, the treatment of course 
consists in removing the cause, when the effect will 
go with it. 



CHAPTER XVII 

RECTAL EXAMINATION FOR LIFE INSURANCE. 

To the physician who wishes to be thorough in 
his examinations for life insurance, there are certain 
cases that are of the greatest importance, especially 
when viewed from the standpoint of the companies' 
interests. I refer to the existence of rectal diseases, 
especially cancer, ulceration, syphilis, stricture, and 
fistula. It is well known to any one who does much 
rectal surgery that nearly all diseases that affect these 
parts are called piles, and when the question is asked, 
"Have you had piles, fistula, or any disease of the 
rectum?" the applicant will often answer he is "slightly 
troubled with piles." His so-called piles may, and 
often do, consist of a discharge of blood or a mixture 
of mucus, pus, and blood, indicating cancer, ulceration, 
or stricture, but the examiner will, in nearly all cases, 
record the answer as given, or, at the suggestion of the 
agent, if present, will answer the question in the neg- 
ative, as "it is of no importance and makes the exam- 
ination look bad." 

For the benefit of the company about to assume 
the risk, such cases should be submitted to a careful 
and thorough examination. The importance of phys- 
ical examinations is so great that all companies are 
very careful to secure only competent examiners, so 
that no risk may be assumed below a certain physical 
standard. The lungs, heart, and kidneys are examined 
with great care, while the last four inches of the in- 

200 



EXAMINATION FOR LIFE INSURANCE 201 

testinal canal, which is more likely to be diseased than 
any of the others, is entirely ignored. 

Coley, in the ''Twentieth Century Practice," states 
that "four per cent of all cancers occur in the rectum, 
and Sutton, as reported by Mayo, of Rochester, says, 
of one hundred cases of intestinal carcinoma, seventy- 
five will be in the rectum, twenty- three in the large 
intestine, and only two in the small intestine." Out 
of three hundred and fifty-four deaths reported to one 
of our largest insurance companies, I find that two died 
from cancer of the rectum, two from ulceration of 
the rectum, one from consumption of the bowels, and 
one from dysentry. The two last were most likely 
due to ulceration or cancer. In addition to the above 
there were eleven deaths due to cancer, whose location 
is not stated. This gives a percentage of not less than 
two deaths per hundred due to rectal cancer. These 
persons' average age was about forty years, and some 
of them had taken out their insurance less than a year 
previous to their death. It is only reasonable to sup- 
pose that in at least a part of the cases the disease could 
have been discovered at the time the examination was 
made. Granting this to be the case, justice was not 
done the company which assumed the risks. 

I wish to report a few cases which will illustrate 
fully my views of this matter. 

Mr. W., age thirty-seven, applied for insurance in 
one of our old line companies. His family history 
was good, with the exception that his mother's mother 
had died of phthisis and one sister had died of some 
trouble following confinement, not satisfactorily ex- 
plained, but as she was ill about two months, I looked 
upon her case with suspicion. Mr. W. was apparently 
in perfect health in every way with the exception that 
he "was troubled a little with piles." Upon examining 



202 TREATMENT OF RECTAL DISEASES 

the rectum, I could not find any hemorrhoids, or in 
fact, any well-defined disease other than a slight 
moisture which seemed to come from a fistula, but by 
the most painstaking efforts I could not find any fistul- 
ous opening. Still, the tissues around the anus did 
not look healthy, and I declined to recommend the 
risk for a period of three months, which would give 
sufficient time for any diseased condition to develop. 
The agent who solicited the risk was not satisfied with 
this, as it caused the loss of a good commission to him, 
so he took the applicant to another examiner, who 
passed him, entirely ignoring the rectal trouble. In 
less than three months a tubercular fistula made its 
appearance, and in about eighteen months the appli- 
cant died of general tuberculosis. 

In speaking of cancer of the rectum, Kelsey, in 
his last work on "Diseases of the Rectum and Pelvis," 
says : "It is often astonishing to the surgeon to meet 
with an advanced case of scirrhus, in which the caliber 
of the bowel is so nearly occluded as scarcely to admit 
the passage of the finger, and yet in which the patient 
has never had sufficient uneasiness to call for a direct 
rectal examination." 

Dr. Matthews, in his work on rectal diseases, re- 
lates the following case, which shows the importance 
of an examination: "Mr. C, about forty-five years 
old, came to me at the suggestion of his physician 
for an examination of his rectum. He remarked that 
his doctor was not sure that he had any rectal disease, 
nor was he, yet because of the fact that he strained 
at stool and passed a little blood and mucus, he thought 
it best to be examined. Placing him in the Sims's po- 
sition, and in a good light, I carefully searched the 
rectum with a speculum, but could find no disease. 
Removing the instrument, I introduced my finger, and 



EXAMINATION FOR LIFE INSURANCE 203 

asked the patient to strain down, when I was enabled 
to explore the gnt five or six inches. At the end of 
my finger I detected an indurated spot, which seemed 
to extend upward. Reasoning by exclusion, I could 
not imagine any other disease than cancer that could 
cause this hard, nodulous, little tumor, located at this 
spot. Although there was no glandular involvement, 
I was thoroughly of the opinion that this man had in- 
cipent cancer. He was given treatment by injections, 
etc., and in a few days his symptoms cleared up, and 
there was no discharge of either blood or mucus, and 
no straining at stool. 

After this he took a long journey of about fifteen 
hundred miles, and upon his return he called at my 
office to say that he had entirely recovered. He had 
a respite from all bad symptoms for a month or six 
weeks. During this interim he applied for a policy 
of ten thousand dollars, passed the examination, no 
attention being paid to the rectum, and was insured. 
After a while his condition grew worse ; a discharge 
of blood and mucus was noticed ; he began to emaciate ; 
took on a bad color ; and in less than six months per- 
foration took place, and he died — of cancer." 

The next disease of which I wish to speak, is ulcer- 
ation. When Ave consider the following symptoms of 
the disease, it is readily seen that an applicant who said 
that he was troubled with piles would be passed with- 
out question by the average examiner, if the applica- 
tion was made before the disease had progressed too 
far. The first thing noticed by the patient in this dis- 
ease is a diarrhoea, which is worse in the morning. 
Often there will be two or three passages before break- 
fast, and but little is passed, except mucus, or, as the 
patient describes it, "like the white of an egg" ; he may 
also complain of tenesmus, and say that "there seems 



204 TREATMENT OF RECTAL DISEASES 

to still be something more to pass," but he is unable 
to relieve himself of it. Probably after breakfast he 
will have a normal movement, and go through the 
day with but little inconvenience ; later he will find 
the passages more frequent, and often smeared with 
blood. This may last for months, gradually getting 
worse ; more blood and pus will be seen in the stools, 
and they will often have a coffee-ground appearance, 
as is seen in ulceration of the stomach. This condi- 
tion is a very serious one, and will end in stricture, re- 
quiring the gravest surgical procedures to effect a cure, 
and in a majority of instances, death is the result. 
These cases are by no means rare, and nothing in 
the whole list of human ailments requires more skill 
to effect a cure. I devote this much space to symp- 
toms to show that while the disease is a serious one, 
it can be diagnosed in its early stages, and the company 
to whom application is made prevented from accepting 
a risk that will soon die on their hands. 

As illustrating the above condition, I would cite 
the following case. Mr. B., age about forty, consulted 
me because he was "troubled with piles." He stated 
that he felt a little pain of a dull, burning character, 
and had some discharge of ''white stuff," and occasion- 
ally the movements were "streaked with blood." It 
did not bother him much, but he wished to see what I 
thought about it. He did not think it of enough im- 
portance to submit to an examination, even after I had 
explained to him the probable cause and result of his 
disease. He consulted another physician, who told 
him that it was "nothing that amounted to anything," 
and gave him some medicine to take which would 
"make matters all right in a few days." At this time 
Mr. B. was in good health, except for the trouble 
spoken of, and would have been accepted by almost 



EXAMINATION FOR LIFE INSURANCE 205 

any company to whom he might have applied for in- 
surance, as a majority of the examiners would have 
entirely ignored the rectal trouble. Shortly after con- 
sulting me he moved to another town, and I did not 
see him for several months ; then one day he came into 
my office, and was so pale and emaciated that I scarce- 
ly knew him ; he told me that he had lost fifty pounds 
in weight, and that his bowels were moving from ten 
to twenty times daily ; his physician, he said, was treat- 
ing him for intestinal consumption. He died soon 
after this. 

There are many cases of chronic proctitis, or rectal 
catarrh that are easily recognized if the proper meth- 
ods of diagnosis are adopted, and which usually yield 
promptly to treatment. These affections are most 
often found among men of middle age, especially 
those whose occupations are largely out of doors, 
where they are exposed to sudden changes of temper- 
ature. This condition is largely responsible for the 
considerable number of cases of chronic diarrhoea 
among our old soldiers, and is directly due to the expo- 
sure and hardships incident to camp-life, especially 
sitting and sleeping on cold, damp ground. Many of 
these people die after only a few years of suffering 
from this disease or from some other comparatively 
trivial affection complicating it ; again, it may assume 
an ulcerative form and result in stricture and death. 
There is a long period of time in most of these cases, 
during which the disease is easily recognized, but it 
may not present symptoms sufficiently well marked to 
prevent an applicant from passing a satisfactory ex- 
amination. 

I believe all who will give this matter careful atten- 
tion will agree with me that the conditions outlined 
above are very important and deserve the serious and 



206 TREATMENT OF RECTAL DISEASES 

careful attention of all examiners who have at heart 
the best interests of the companies they represent. 

I do not wish to be understood as advocating a 
careful rectal examination in all cases, but only in 
those where it seems indicated. 



CHAPTER XVIII 

COLOSTOMY: TECHNIQUE OF OPERATION AND 
RESULTS. 

The question of changing the course of the fecal 
current in inoperable affections of the lower bowel 
and causing it to flow from the body in some other 
place than that intended by nature is one that has been 
before the profession from the earliest recorded his- 
tory of surgery. Many think that it leaves the patient 
in a condition pitiable in the extreme and disgusting 
to himself as well as to those around him, and that 
death would be preferable. As the operation was 
formerly done this was true, but modern surgery has 
so improved the technique, and nature's method of 
closing the external orifice by a sphincter muscle is so 
closely simulated, that many of the unpleasant features 
are eliminated. 

There are two general indications for doing this 
operation. The first is to divert the fecal current from 
the lower bowel temporarily until operative or other 
measures have cured the disease below, when the arti- 
ficial opening is closed and the natural channel again 
established. The other it to make a permanent artificial 
anus, because of inoperable disease or malformation 
below the opening. Until within recent years a tem- 
porary opening was seldom made, but if an opening 
was made the patient was expected to carry it with 
him to the grave. At the present time an opening is 
made more often than should be done, and for insuffi- 
cient reasons. If such an operation seems indicated, 

207 



208 TREATMENT OF RECTAL DISEASES 

all sides of the matter should have careful considera- 
tion, and it should never be done except for good 
reasons, as there is considerable danger in making the 
opening and even more in closing it. Wheeler esti- 
mated the mortality at 25 per cent., but this was be- 
fore the days of aseptic surgery. It should also be 
remembered that many patients are almost ready to 
die when they come for operation. Of course in per- 
fectly healthy subjects, if proper precautions are ob- 
served, there should be a very small mortality, probably 
not more than 1 or 2 per cent. 

While the operation for either temporary or per- 
manent colostomy may not be considered as major 
surgery, they both require an attention to detail and 
technique of the most painstaking character. Nothing 
that I can think of will cause more suffering and 
mental agony during the remaining life of the patient 
than a poorly done colostomy. 

I will speak only of the operation as done in the left 
inguinal region, as this is the one most often done. 
In doing the operation, for temporary purposes make 
an incision about two inches long one and one-half 
inches above the ant. sup. spinous process, crossing an 
imaginary line drawn from the process to the umbili- 
cus, about one-third above and two-thirds below the 
above line. After going through the skin and super- 
ficial fascia, the fibres of the internal and external 
oblique are separated but not cut. After dividing the 
peritoneum it is brought out and attached to the skin 
with fine catgut. Next, the colon is. searched for and 
usually found with but little trouble. Here an im- 
portant point is to be observed, and that is, to draw 
the upper portion of the colon down until a short mes- 
entery is found, letting the redundant portion pass 
back into the abdomen through the lower part of the 



COLOSTOMY 



209 



incision. If this is not done, there is sure to be a 
prolapse of the upper part of the gut, which will be 
very annoying to the patient. The next important 
point is to get a good spur ; that is, to get the bowel 
out far enough so that all the fecal matter coming 
from above will pass out of the bowel and none of it go 
into the lower portion. 

As this is to be a temporary opening, it is important 
that some arrangement be made so that it may be 
closed easilv when it is thought best to do so. In 




Fig. 58. Inquinal Colostomy. — (Bodine). 



order to do this the bowel should be pulled out and the 
two apposing edges united by catgut ligatures for two 
and a half to three inches to prevent coils of small in- 
testines or other structures getting between and being 
clasped in the clamp that is used to divide the w r alls 
later. This particular part of the operation should be 
credited to Bodine, who originated it. (See fig. 58.) 

The bowel is now dropped back into the abdomen 
until the posterior wall is level with the skin. A glass 
rod is forced through the mesentery just beneath the 



210 



TREATMENT OF RECTAL DISEASES 



bowel wall, with the ends resting on the abdomen at 
each side of the opening to hold the bowel out suffi- 
ciently to make a good spur. The skin and bowel wall 
are now carefully united with silk all the way around. 
If this is not done, other coils of intestine may be 
forced out by the side of the one intended to be out. 

If the necessity for opening the bowel is not urgent, 
it should be left for forty-eight hours until adhesions 
have formed so that the peritoneum may not become 
infected. When the opening is made cocaine may be 
used and the bowel pared off about one-half inch above 
the skin, leaving a typical double-barrel opening. 




Fig. 59. Enterotomy after Colotomy. — (Bodine), 



When it is desired to divert the fecal current to its 
natural channel again the three-inch septum may be 
cut through by applying an ordinary long- jawed for- 
ceps and leaving it on until it cuts itself loose. (See 

fig- 590 

Should the external opening not close entirely, a 
slight plastic operation may be done under cocaine an- 
aesthesia to close it. 



COLOSTOMY 



211 



In case the artificial opening - is to be permanent, a 
different method should be employed. The incision 
should be made about an inch nearer the umbilicus 
than in the other case. The peritoneum is not brought 
out and stitched to the skin. The bowel is brought out 
and pulled down until a short mesentery is found and 
then cut in two, the lower end of the opening closed 
and dropped back into the abdomen. We now have 
nothing but the upper end to deal with. Another in- 




Fig. GO. Showing how the bowel passes between the 
superficial fascia and external oblique muscle for about 
an inch before emerging through the skin. 



cision is now made the same length as the first one an 
inch below and parallel with it, extending through the 
skin and superficial fascia only. The bridge of tissue 
separating the two incisions is now undermined be- 
tween the superficial fascia and the external oblique 
and the bowel drawn through the tunnel thus made and 



212 TREATMENT OF RECTAL DISEASES 

stitched to the edge of the opening. The upper opening 
is now closed down to where the bowel makes its turn 
into the tunnel. 

We now have not only the fibers of the two oblique 
muscles closing the bowel but we have also the bridge 
of skin shutting off the end and acting as a sphincter 
muscle. This will allow but very little, if any, leakage 
and considerable force must be applied by the abdom- 
inal muscles to cause fecal matter to be expelled. 
(See fig. 60.) 

This is nearly the same operation as described by 
Tuttle in his new work on rectal surgery, but varies in 
some of the details, especially in dropping the lower 
end of the bowel back into the abdomen. I believe 
that the risk incurred in dividing the bowel and drop- 
ping it back is so small compared with benefits de- 
rived that it is better that it be done. 

With the improved methods of treating malignant 
and syphilitic rectal diseases, together with improved 
methods of making an early diagnosis, the indications 
for doing colostomy operations are less than formerly 
existed. It is of course an operation to be avoided if 
possible. At the very best it is an operation that has 
a very depressing mental effect, and many patients 
suffer very severely because of the unnatural opening, 
even though from a mechanical and surgical stand- 
point it works to perfection. Yet in spite of this the pa- 
tient's life may often be prolonged and much physical 
suffering avoided by a properly done colostomy. They 
soon learn how best to care for themselves, and by the 
use of snugly fitted bandages, or in some cases steel 
springs in the form of a truss, they have but little 
trouble and pass the remainder of their days in com- 
parative comfort. It will, beyond doubt, prolong life, 
in some cases a year or more, — and by relieving pain, 



COLOSTOMY 213 

checking diarrhoea and hemorrhage, and preventing the 
almost complete obstruction that occurs in nearly all 
of these cases, the patient is more than repaid for the 
inconvenience and the care he is obliged to give the un- 
natural opening. 

I know of no more helpless position in which to 
place a surgeon than to have to care for a rectal cancer 
in its last stages unless he be allowed to seek relief, not 
only for the patient, but for himself, in a colostomy. 



CHAPTER XIX. 
LOCAL ANESTHESIA. 

As this work deals almost entirely with local anaes- 
thesia, and as no doubt many think that some of the 
operations described cannot be done except under the 
influences of general anaesthetics, I wish to say a few 
words upon this subject. 

There are several different means by which the 
tissues may be rendered nonsensitive. The quickest 
and easiest is by the use of the ethyl chloride spray 
by which the parts are frozen. This however causes so 
much pain when the tissues begin to thaw that it is 
not very satisfactory, especially if the mucous mem- 
brane is involved as it causes such a burning sensation 
that the patient would prefer to stand the pain of the 
operation rather than the freezing and thawing of 
the tissues. 

It has been recommended by good authority to 
give the patient a big drink of whisky fifteen or twenty 
minutes before operating, to be followed five minutes 
before the operation by one fourth grain of morphine 
sulph. This will reduce the pain to a minimum and 
with some patients is very satisfactory but the moral 
effect is bad and you may unwittingly start your pa- 
tient on the road to a drunkard's grave or restart one 
who is making a serious effort to reform. 

I have used cocaine or eucaine "B" in my practice 
for several years, and if properly managed think them 
perfectly safe. Cocaine, I think, is the better anaes- 
thetic but is more toxic, still if not much is needed in 
a given case I always use it as it seems to have a better 
effect. If the operation is quite extensive I use the 
eucaine "B". 

214 



LOCAL ANAESTHESIA 215 

There has recently been going the rounds of the 
medical press extracts from a paper on the use of 
sterile water injected into the tissues to produce free- 
dom from pain in rectal surgery. This idea is not 
new, as I recommended it in the first edition of this 
book in 1901 and it had been used by me for ten years 
prior to this. It is not suitable to all cases but only 
such operations as may be in tissue that can be made 
tense by the distension of the water and kept so for 
several minutes. 

If the injection be made in loose connective tissue 
where the water spreads rapidly over a large field it 
will have but little effect, and, as the small amount 
of cocaine needed to produce the required effect is 
absolutely harmless it should be used. 

I have used cocaine and eucaine in probably a 
thousand cases and have never seen any toxic effect 
that was at all alarming. During the past year I have 
been adding a few drops of adrenlin solution and find 
that it is beneficial in driving out the blood and hold- 
ing the cocaine in contact with the tissues for a longer 
time. 

I think most operators use too strong a solution. 
One says sixteen per cent. I never use more than four 
per cent where it is injected and ten per cent where 
it is applied locally to mucus membrane, and many 
times do not use more than half the above strength. 
I would prefer to inject thirty drops of a two per cent 
solution rather than fifteen drops of a four per cent 
solution. If the incision is made before the fluid has 
had time to all absorb, a large part of it will run out 
with the blood, and of course lessen the systemic effect, 
thirty drops of a two per cent solution may safely be 
injected into the tissues. This would be only a fraction 



21G TREATMENT OF RECTAL DISEASES 

more than a half grain, and is more than is actually 
needed in -most cases. If the eucaine "B" is used, 
fully twice the above strength may be employed. Ten 
drops of a two per cent solution injected into a prolap- 
sed pile of medium size will render it absolutely devoid 
of sensation so that it may be handled in any way de- 
sired. 

The Schleich formula made in tablets is very 
convenient. Each tablet contains, cocaine I gr. mor- 
phine y 2 gr. sodium chloride 2 gr. 

One tablet added to sixty drops of water makes a 
solution of not quite two per cent of cocaine. Only 
fresh solutions should be used. 

The temperment of the patient has much to do 
with the success of the procedure. Some nervous per- 
sons are very easily frightened and the sight of the 
surgeon and the instruments will make them so restless 
and uneasy that it is impossible to do anything with 
them. On the other hand it is often the fault of the 
surgeon. If he is nervous and awkward and goes 
about his work as though he did not know what he 
was trying to do he cannot help but impart the same 
feeling to his patient. 

I have recently been experimenting with electri- 
city to drive cocaine into the tissues by cataphoresis 
as suggested in the following, taken from the Lancet : — 
"The method outlined is as follows: A solution con- 
sisting of adrenalin chloride two drachms, cocaine 
five grains and water one-half ounce is prepared. Lint 
is folded into a pad of four layers, soaked in the solu- 
tion, and placed under a positive electrode. A large 
negative electrode is applied elsewhere, and a current 
of from fifteen to thirty miliamperes is slowly induced 
and run for a space of from five to fifteen minutes. 
The surface may then be washed with ether, and super- 



LOCAL ANESTHESIA 217 

ficial operations performed painlessly and without the 
loss of blood." 

I have not had sufficient experience with this 
method to know just what there is in it, but believe 
that it will prove of great value in many cases. 

I had made a copper rectal electrode (see cut on 
page 67) which w T hen wrapped with gauze soaked in 
cocaine solution is introduced into the bowel and the 
positive cord attached. The negative pole is applied 
elsewhere and a current of about fifteen miliamperes 
turned on. 

I hope by this method to be able to so anaesthetize 
the sphincter muscles that they may be completely 
divulsed in the office. If this can be done, much of 
the difficulties of doing rectal surgery without general 
anaesthetics, will be overcome. 

There are many reasons why all operations pos- 
sible sKbuld be done under local anaesthetics. 

1st: — It removes all danger from death due to the 
anaesthetic. 

2nd : — It avoids the danger of post operative com- 
plications and the effect on some of the internal organs 
from chloroform or ether. 

3rd: — There is no period of unconsciousness, which 
seems so horrible to the friends and which is often 
followed by severe nausea and vomiting. 

4th : — Many persons who are conscious will render 
valuable assistance to the operator. 

5th : — Many will come for operations who would 
not do so if they thought they had to take chloroform 
or ether. 

As has been stated before, this work requires atten- 
tion to details, tact, judgment, gentleness, and courage. 
Without these no physician will meet with a great 
measure of success in anv branch of his calling ; with 



218 TREATMENT OF RECTAL DISEASES 

them he will surely prosper, both professionally and 
financially. 

In closing, I wish to quote an editorial extract 
from the International Journal of Surgery, on local 
anaesthesia, taken from the issue of February, 1899. 

"It is remarkable how unimportant a place local 
anaesthesia still occupies in surgery. It is an indisput- 
able fact that complete anaesthesia is still, and will 
always remain, a matter of dread to patients, and that 
surgeons do not make any very strenuous endeavors 
to avoid it when they could possibly do without it. 
The most profitable work for surgeons is often con- 
nected with the painless treatment of common affec- 
tions, such as piles, in people who would subject them- 
selves to ordinary operative measures were it not for 
the fear of anaesthesia. In chloride of ethyl ('Kelene') 
and the subcutaneous employment of cocaine and 
eucaine" (better still, by means of the new Cocaine- 
Kelene Autospray,) "we have means that are not 
really half studied out, and which deserve more careful 
consideration than they have yet obtained. The writer 
has operated for piles and fistula, has removed the 
clavicle with Schleich/s infiltration anaesthesia and 
chloride of ethyl ('Kelene'). The use of the latter, 
prior to the inserting of the hypodermic needle, is 
often of advantage, as its insertion, in cases of in- 
growing nails and infected fingers, is often almost as 
painful as the operation itself. The ophthalmologists 
are nearly the only ones who use local anaesthesia to 
the full extent of its possibilities, and we expect to 
see practitioners of other branches of surgery, in the 
near future, more eager to extend the scope of local 
anaesthesia, both for the welfare of the patients and 
for the increased facility with which they will find that 
patients will submit to necessary procedures." 



INDEX. 



9G 



Abscess, etiology of, 91 
ischo-rectal, 93 
pelvic-rectal, 
submucous, 95 
symptoms and diagnosis, 

9G-100 
treatment of, 100-2 

Adenoma, 149 

Advance information, 34-5 

Anaesthesia, local, 214 
when not required, 31 

Anatomy, 36 

Angioma, 152 

Arteries, inferior hemorrhoid- 
al, 45 
middle hemorrhoidal, 44 
superior hemorrhoidal, 44 



Bones of pelvis, sacrum and 
coccyx, 36 

Bowels, regularity of, 52 

Bowel wall, perforation of, 
172 



Bowel, perforation and treat- 
ment of, 173 

Cachexia, 28 

Cancer, rectal, diagnosis, 
symptoms and treatment 
of, 189-94 

Carcinoma, 27 

Card, record, 35 

Catarrh, rectal, 205-6 

Caustics, injection of, 112-13 

Cleanliness, necessity for, 
22-3 

Coat, the muscular of rec- 
tum, 43 



Coat, the serous, of rectum, 42 
Cocaine, use of, 215 
Coccygeus, 39 
Coccyx, bones of, 36 
Colitis, ulcerative, 131 
Colon, irrigation of, 133-5 
219 



220 



INDEX. 



Colostomy, technique 
operation, 207-13 



and 



Constipation, 51-4 

Constitutional symptoms, 28 

Cystoma, 151 

Diagnosis, general considera- 
tion of, 21 

Diarrhoea, 27-28 

Diet, importance of, 159 

Difficulty in diagnosis of rec- 
tal diseases, 21 

dilatation, gradual, 125 

Dilatation of sphincter, G7 

Discharge of mucous, pus etc. 

27 

Drugs, use sparingly, 53 

Enema of water, 128 

Etiology of abscess, 91 

Etiology of fistula, 103 

Examination, instrumental, 30 

Examination, physical, 28 

Examination, preparation for, 
22-3 

Examination, rectal for life 
insurance, 200 

Exploratory laparotomy, 32- 
33 

Feces, incontinence of, 119 

Fibroma, 150 

Fissure, 27 

Fistula, after treatment, 117- 
119 



Fistula, complete, 107-9 

Fistula, etiology of, 103 

Fistula, horseshoe, 117 
after treatment, 117 
complications, 118 
incomplete external, 105 
internal, 10G 
location, 104 

preparation of patient, 115 
symptoms and diagnosis, 

104 
treatment of, 109-15 

Fossa, the ischio-rectal, 49 

Growths, non-malignant, 14G 

Growths, symptoms and diag- 
nosis, 148-53 

Hemorrhage. 27 

Hemorrhoidal, inferior arter- 
ies, 45 
middle arteries, 44 
superior arteries, 44 

Hemorrhoids, capillary, 59 
cause of, 55-8 
classification of, 58-G2 
cutaneous, CO 
palliative treatment of, 64- 

5 
thrombotic, 58 
treatment of, G2-9 
venous, 59 

Ichthyol-prescription, 123 

Internal sphincter, 37 

Irrigator, description of, 22 

Ischio-rectal region, 48 

Levator Ani, 37-8 



INDEX. 



221 



Ligature, elastic, 112 
Lipoma, 151 

Malformations, congenital, 

183-88 

Methods of diagnosis, 26 

Mucous, discharge of, 27 

Muscles of rectal region, 37 

Nerves of rectal region, 47 

Nerves, spinal, 47 

Nervousness, 28 

Orthoform, 122 

Operation by incision, 124 

Pain, its value in suggestion, 
2G 

Papilloma, 151 

Patients, lady, examination 
of, 24-5 

Pelvis, bones of, 3G 

Perineum, and ischo-rectal 

region, 48 
Physical examination, 28 

Piles, clamp and cautery 
operation, 8G-9 
injection method of treat- 
ment, formulses etc., 69- 
79 
method of operating, 73 
operation by electrolysis 

90 
operation by ligature, 82-5 
operation with continuous 

suture clamp, 80-1 
operation with notched 
clamp, 82 



Position of patient, 28 

Preparation for examination, 
22-3 
for patient, 28 

Proctitis and sigmoiditis, 
154-60 

Prolapsus of rectum, symp- 
toms and Diagnosis of, 
136-45 

Protrusion at stool, 26 

Pruritus Ani and Treatment, 

175-82 
Pus, discharge of, 27 

Rectal diseases, difficult to 

diagnose, 21 
Rectal diseases, reflex action, 

195-99 
Rectal region, veins of, 45 

Receiving information con- 
cerning preparation for 
examination, 22-3 

Rectum, complete, 136 

Rectum, lower portion of, 42 

incomplete, 136 

middle portion of, 41 

muscular coat, 42 

prolapsus and treatment of, 
136-45 

relations of, 41 

submucous coat, 43 

structure of, 42 

the, 39-40 

upper portion of, 41 

what diseases may be diag- 
nosed with unaided eye, 
24 

catarrhal diseases of and 
formulas, 178-82 



222 



INDEX. 



Reflex action, 196 

Sacrum, bones of, 36 

Sigmoid, ulceration of, 130 

Sphincter, external, 36-7 
internal, 37 

Stool, protrusion at, 26 

Stricture, malignant, 167 

Stricture, non-malignant, 166 
pressure from without, 162 
spasmodic, 161 
symptoms and diagnosis, 

164-70 
tubercular, 162 
traumatic, 162-3 
venereal, 164 

Suggestion, the value of pain 
in, 26 

Transversus Perinei, 39 

Tumor, classification of, 148 
symptoms and diagnosis, 

148 
where generally located, 

147 



Teratoma, 151 

"Ulcer, irritable, or fissure, 120 

Ulcer, rectal, and treatment, 

126-30-203-4 
rodent, 129 

Ulceration, and treatment of, 
120-6 

Ulceration of the sigmoid, 
symptoms and treatment, 
130-33 

Ulcer, Powder for and formu- 
lae, 122 

Veins, middle and inferior 
hemorrhoidal, 46 

Veins of rectal region, supe- 
rior hemorrhoidal, 45-6 

Veins, varicose, 129 

Waters, mineral, 53 

Wounds and the injuries and 
treatment, 171-4 



JUL 24 19C5 



